Basic Information
Provider Information | |||||||||
NPI: | 1124150859 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY EVERETT-NORTH PHARMACY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8609 EVERGREEN WAY | ||||||||
Address2: |   | ||||||||
City: | EVERETT | ||||||||
State: | WA | ||||||||
PostalCode: | 982082619 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4257893700 | ||||||||
FaxNumber: | 4257893750 | ||||||||
Practice Location | |||||||||
Address1: | 1424 BROADWAY | ||||||||
Address2: |   | ||||||||
City: | EVERETT | ||||||||
State: | WA | ||||||||
PostalCode: | 982011720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4257892050 | ||||||||
FaxNumber: | 4257892070 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/09/2007 | ||||||||
LastUpdateDate: | 07/14/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FARRRELL | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 4257893700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | COMMUNITY HEALTH CENTER OF SNOHOMISH COUNTY | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | CF00056988 | WA | Y |   | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 6024780 | 05 | WA |   | MEDICAID |