Provider Demographics
NPI:1679651970
Name:EASTERN STATE HOSPITAL PHARMACY
Entity Type:Organization
Organization Name:EASTERN STATE HOSPITAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RONDA
Authorized Official - Middle Name:D
Authorized Official - Last Name:KENNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MPA
Authorized Official - Phone:509-565-4659
Mailing Address - Street 1:850 MAPLE STREET
Mailing Address - Street 2:
Mailing Address - City:MEDICAL LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99022
Mailing Address - Country:US
Mailing Address - Phone:509-565-4659
Mailing Address - Fax:509-565-7015
Practice Address - Street 1:800 WEST MAPLE STREET
Practice Address - Street 2:
Practice Address - City:MEDICAL LAKE
Practice Address - State:WA
Practice Address - Zip Code:99022-0800
Practice Address - Country:US
Practice Address - Phone:509-299-3121
Practice Address - Fax:509-299-7015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336L0003XSuppliersPharmacyLong Term Care PharmacyGroup - Single Specialty
No283Q00000XHospitalsPsychiatric HospitalGroup - Single Specialty