Provider Demographics
NPI:1821271271
Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Other - Org Name:PROVIDENCE HEALTH PARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:HOFHEINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-525-3939
Mailing Address - Street 1:PO BOX 196276
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99519-6276
Mailing Address - Country:US
Mailing Address - Phone:907-212-6868
Mailing Address - Fax:
Practice Address - Street 1:3841 PIPER ST
Practice Address - Street 2:SUITE U230
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4624
Practice Address - Country:US
Practice Address - Phone:907-212-6868
Practice Address - Fax:907-212-4955
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-07
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPH5893Medicaid
AKPH5893Medicaid