Provider Demographics
NPI:1821635186
Name:FERNDALE PHARMACY LLC
Entity Type:Organization
Organization Name:FERNDALE PHARMACY LLC
Other - Org Name:FERNDALE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-325-4310
Mailing Address - Street 1:PO BOX 622
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248-0622
Mailing Address - Country:US
Mailing Address - Phone:360-325-4310
Mailing Address - Fax:360-325-4320
Practice Address - Street 1:2057 ALDER STREET
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248
Practice Address - Country:US
Practice Address - Phone:360-325-4310
Practice Address - Fax:360-325-4320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-05
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2154388Medicaid