Provider Demographics
NPI:1619090487
Name:KENNEWICK GENERAL HOSITAL
Entity Type:Organization
Organization Name:KENNEWICK GENERAL HOSITAL
Other - Org Name:THE PHARMACY AT TRIOS SOUTHRIDGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHCY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-221-7351
Mailing Address - Street 1:3730 PLAZA WAY
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99338-2718
Mailing Address - Country:US
Mailing Address - Phone:509-221-6150
Mailing Address - Fax:509-221-6151
Practice Address - Street 1:521 N YOUNG ST
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7806
Practice Address - Country:US
Practice Address - Phone:509-221-6150
Practice Address - Fax:509-221-6151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X
WACF0000568833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2107413OtherPK
WA6025795Medicaid