Provider Demographics
NPI:1619193570
Name:TULALIP CLINICAL PHARMACY
Entity Type:Organization
Organization Name:TULALIP CLINICAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-716-2664
Mailing Address - Street 1:8825 34TH AVE NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:TULALIP
Mailing Address - State:WA
Mailing Address - Zip Code:98271-8085
Mailing Address - Country:US
Mailing Address - Phone:360-716-2660
Mailing Address - Fax:360-716-3660
Practice Address - Street 1:8825 34TH AVE NE
Practice Address - Street 2:SUITE A
Practice Address - City:TULALIP
Practice Address - State:WA
Practice Address - Zip Code:98271-8085
Practice Address - Country:US
Practice Address - Phone:360-716-2660
Practice Address - Fax:360-716-3660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332800000X
WACF00055944333600000X, 3336C0002X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6019939Medicaid
WA6682830001Medicare NSC