Provider Demographics
NPI:1700880291
Name:VIRGINIA MASON MEDICAL CENTER
Entity Type:Organization
Organization Name:VIRGINIA MASON MEDICAL CENTER
Other - Org Name:VIRGINIA MASON LINDEMAN PAVILION PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:RICCERI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-341-0550
Mailing Address - Street 1:1201 TERRY AVE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-2735
Mailing Address - Country:US
Mailing Address - Phone:206-625-7202
Mailing Address - Fax:206-625-7216
Practice Address - Street 1:1201 TERRY AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2735
Practice Address - Country:US
Practice Address - Phone:206-625-7202
Practice Address - Fax:206-625-7216
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VIRGINIA MASON MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-13
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
WACF000037153336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6008452Medicaid
2108790OtherPK
WA4920155OtherNCPDP