Provider Demographics
NPI:1205043296
Name:PEACEHEALTH ST JOHN MEDICAL CENTER
Entity Type:Organization
Organization Name:PEACEHEALTH ST JOHN MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL DIRECTOR, PHARMACY SERVICE
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-414-7821
Mailing Address - Street 1:1615 DELAWARE ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2310
Mailing Address - Country:US
Mailing Address - Phone:360-414-7821
Mailing Address - Fax:360-414-7366
Practice Address - Street 1:1615 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2310
Practice Address - Country:US
Practice Address - Phone:360-414-7821
Practice Address - Fax:360-414-7366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHF000010141835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapyGroup - Single Specialty