Provider Demographics
NPI:1952426645
Name:WA VETERANS HOME PHARMACY
Entity Type:Organization
Organization Name:WA VETERANS HOME PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:WESTHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-725-2171
Mailing Address - Street 1:1141 BEACH DR E
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-4937
Mailing Address - Country:US
Mailing Address - Phone:360-895-4700
Mailing Address - Fax:360-895-4453
Practice Address - Street 1:1141 BEACH DR E
Practice Address - Street 2:
Practice Address - City:RETSIL
Practice Address - State:WA
Practice Address - Zip Code:98378
Practice Address - Country:US
Practice Address - Phone:360-895-4700
Practice Address - Fax:360-895-4452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X
WAFL000011693336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6015010Medicaid
4906092OtherNABP
WA4906092OtherNADP