Provider Demographics
NPI:1316194525
Name:WESTERN PHARMACY GROUP LLC
Entity Type:Organization
Organization Name:WESTERN PHARMACY GROUP LLC
Other - Org Name:MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FARIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-220-4818
Mailing Address - Street 1:851 COHO WAY STE 312
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-2066
Mailing Address - Country:US
Mailing Address - Phone:360-685-4263
Mailing Address - Fax:
Practice Address - Street 1:2995 NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-2419
Practice Address - Country:US
Practice Address - Phone:619-525-1551
Practice Address - Fax:619-234-1064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-20
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336L0003X
CA559033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2176003OtherPK
CAPHA491590Medicaid