Provider Demographics
NPI:1750948956
Name:LACEY SQUARE PHARMACY INC
Entity type:Organization
Organization Name:LACEY SQUARE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDERSON
Authorized Official - Middle Name:SHAWN
Authorized Official - Last Name:JOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:425-251-6335
Mailing Address - Street 1:1412 SW 43RD ST STE 120
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4803
Mailing Address - Country:US
Mailing Address - Phone:425-251-6335
Mailing Address - Fax:
Practice Address - Street 1:6020 PACIFIC AVE SE STE C
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1319
Practice Address - Country:US
Practice Address - Phone:425-251-6335
Practice Address - Fax:425-251-6337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPHAR.CF.60953133OtherWA PHARMACY LICENSE