Provider Demographics
NPI:1710533351
Name:LJS FURNESS DRUG
Entity Type:Organization
Organization Name:LJS FURNESS DRUG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:M
Authorized Official - Last Name:FJERMESTAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-425-3280
Mailing Address - Street 1:114 PACIFIC AVE S
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-1699
Mailing Address - Country:US
Mailing Address - Phone:360-425-3280
Mailing Address - Fax:360-425-0625
Practice Address - Street 1:114 PACIFIC AVE S
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-1699
Practice Address - Country:US
Practice Address - Phone:360-425-3280
Practice Address - Fax:360-425-0625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6005383Medicaid