Provider Demographics
NPI:1295218188
Name:JEFFERSON COUNTY PUBLIC HOSPITAL DISTRICT NO 2
Entity Type:Organization
Organization Name:JEFFERSON COUNTY PUBLIC HOSPITAL DISTRICT NO 2
Other - Org Name:JEFFERSON HEALTHCARE PORT LUDLOW PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-385-2200
Mailing Address - Street 1:834 SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-2443
Mailing Address - Country:US
Mailing Address - Phone:360-385-2200
Mailing Address - Fax:
Practice Address - Street 1:9481 OAK BAY RD STE A
Practice Address - Street 2:
Practice Address - City:PORT LUDLOW
Practice Address - State:WA
Practice Address - Zip Code:98365-9801
Practice Address - Country:US
Practice Address - Phone:360-379-2254
Practice Address - Fax:360-379-2257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-07
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPHAR.CF.60884025OtherLICENSE
WA2126465Medicaid