Provider Demographics
NPI:1225241581
Name:MUCKLESHOOT HEALTH AND WELLNESS CENTER PHARMACY
Entity Type:Organization
Organization Name:MUCKLESHOOT HEALTH AND WELLNESS CENTER PHARMACY
Other - Org Name:MUCKLESHOOT HWC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:253-333-3619
Mailing Address - Street 1:17500 SE 392ND ST
Mailing Address - Street 2:ATTN PHARMACY
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98092-9705
Mailing Address - Country:US
Mailing Address - Phone:253-333-3618
Mailing Address - Fax:253-333-6853
Practice Address - Street 1:17500 SE 392ND ST
Practice Address - Street 2:ATTN PHARMACY
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98092-9705
Practice Address - Country:US
Practice Address - Phone:253-333-3618
Practice Address - Fax:253-333-6853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332800000X
WA332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6016752Medicaid
TEZ001Medicare PIN