Provider Demographics
NPI:1912287731
Name:MULTICARE HEALTH SYSTEMS
Entity Type:Organization
Organization Name:MULTICARE HEALTH SYSTEMS
Other - Org Name:MULTICARE BONNEY LAKE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, AMBULATORY PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:HARBERG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:253-426-6209
Mailing Address - Street 1:10004 204TH AVE E
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-6539
Mailing Address - Country:US
Mailing Address - Phone:253-447-3355
Mailing Address - Fax:253-447-3375
Practice Address - Street 1:10004 204TH AVE E
Practice Address - Street 2:SUITE 1200
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-6539
Practice Address - Country:US
Practice Address - Phone:253-447-3355
Practice Address - Fax:253-447-3375
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MULTICARE HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-24
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X, 3336C0004X, 3336C0004X, 3336M0002X
WAPHARCF602292213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2131570OtherPK
WA2014454Medicaid