Provider Demographics
NPI:1710413224
Name:TULALIP CLINICAL PHARMACY
Entity Type:Organization
Organization Name:TULALIP CLINICAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KELVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-716-2660
Mailing Address - Street 1:8825 34TH AVE NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:QUIL CEDA VILLAGE
Mailing Address - State:WA
Mailing Address - Zip Code:98271-8085
Mailing Address - Country:US
Mailing Address - Phone:360-716-2660
Mailing Address - Fax:
Practice Address - Street 1:8825 34TH AVE NE
Practice Address - Street 2:SUITE A
Practice Address - City:QUIL CEDA VILLAGE
Practice Address - State:WA
Practice Address - Zip Code:98271-8085
Practice Address - Country:US
Practice Address - Phone:360-716-2660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPHAR.CF.000559443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6019939Medicaid