Provider Demographics
NPI:1154451714
Name:PROVIDENCE HEALTH SYSTEM WASHINGTON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH SYSTEM WASHINGTON
Other - Org Name:PROVIDENCE APOTHECARY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:3760 PIPER ST
Mailing Address - Street 2:SUITE 1061
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4683
Mailing Address - Country:US
Mailing Address - Phone:907-212-0256
Mailing Address - Fax:907-212-6547
Practice Address - Street 1:920 COMPASSION CIR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-1645
Practice Address - Country:US
Practice Address - Phone:907-212-9200
Practice Address - Fax:907-212-9280
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-06
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3523336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1028426OtherUPDATED MEDICAID ID