Provider Demographics
NPI:1346595303
Name:PACIFIC NORTHWEST SPECIALTY PHARMACY LLC
Entity Type:Organization
Organization Name:PACIFIC NORTHWEST SPECIALTY PHARMACY LLC
Other - Org Name:PACIFIC NW SPECIALTY PHARMACY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-606-8777
Mailing Address - Street 1:3801 MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663-2258
Mailing Address - Country:US
Mailing Address - Phone:360-448-7890
Mailing Address - Fax:360-448-7258
Practice Address - Street 1:3801 MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-2258
Practice Address - Country:US
Practice Address - Phone:360-448-7890
Practice Address - Fax:360-448-7258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-16
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
WAPHARCF602859053336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2050038Medicaid
2136051OtherPK