Provider Demographics
NPI:1568854859
Name:ROSS, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:ROSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 NW GOLDEN HILLS DR SPC 7
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-8976
Mailing Address - Country:US
Mailing Address - Phone:509-432-6198
Mailing Address - Fax:
Practice Address - Street 1:1690 SE HARVEST DR
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-6000
Practice Address - Country:US
Practice Address - Phone:509-334-2981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60151654183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist