Provider Demographics
NPI:1457366007
Name:NYBERG HEALTH ENTERPRISES INC
Entity type:Organization
Organization Name:NYBERG HEALTH ENTERPRISES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRES AND VP
Authorized Official - Prefix:
Authorized Official - First Name:BROCKMAN/SHANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:NYBERG
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARM
Authorized Official - Phone:425-221-0129
Mailing Address - Street 1:PO BOX 797
Mailing Address - Street 2:
Mailing Address - City:SNOQUALMIE
Mailing Address - State:WA
Mailing Address - Zip Code:98065-0797
Mailing Address - Country:US
Mailing Address - Phone:425-396-7474
Mailing Address - Fax:425-396-7454
Practice Address - Street 1:7730 CENTER BLVD SE
Practice Address - Street 2:
Practice Address - City:SNOQUALMIE
Practice Address - State:WA
Practice Address - Zip Code:98065-8743
Practice Address - Country:US
Practice Address - Phone:425-396-7474
Practice Address - Fax:425-396-7454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WAPHARCF000584963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6028922Medicaid
4931716OtherNCPDP PROVIDER IDENTIFICATION NUMBER