Provider Demographics
NPI:1497273528
Name:MTM CLINICAL CARE RX
Entity Type:Organization
Organization Name:MTM CLINICAL CARE RX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MTM PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:V
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:206-913-9664
Mailing Address - Street 1:20531 76TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98296-5166
Mailing Address - Country:US
Mailing Address - Phone:206-913-9664
Mailing Address - Fax:
Practice Address - Street 1:620 SE EVERETT MALL WAY STE 210B
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-3249
Practice Address - Country:US
Practice Address - Phone:206-913-9664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-09
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1477966612183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1477966612Medicaid
WA1477966612OtherMEDICARE PART-D