Provider Demographics
NPI:1316577869
Name:KSR HEALTH CARE LLC
Entity Type:Organization
Organization Name:KSR HEALTH CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SIMEON
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:360-953-5250
Mailing Address - Street 1:PO BOX 90
Mailing Address - Street 2:
Mailing Address - City:SULTAN
Mailing Address - State:WA
Mailing Address - Zip Code:98294-0090
Mailing Address - Country:US
Mailing Address - Phone:360-953-5250
Mailing Address - Fax:360-569-4161
Practice Address - Street 1:507 W STEVENS AVE STE AAA
Practice Address - Street 2:
Practice Address - City:SULTAN
Practice Address - State:WA
Practice Address - Zip Code:98294-9515
Practice Address - Country:US
Practice Address - Phone:360-953-5250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2132773Medicaid