Basic Information
| Provider Information | |||||||||
| NPI: | 1598831877 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KING COUNTY FINANCE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EASTGATE PUBLIC HEALTH PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 14350 SE EASTGATE WAY | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980076458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062964908 | ||||||||
| FaxNumber: | 2062053095 | ||||||||
| Practice Location | |||||||||
| Address1: | 14350 SE EASTGATE WAY | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980076458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064778190 | ||||||||
| FaxNumber: | 2062058980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 10/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MOE | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | ARDELL | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGEMENT ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2062638807 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | PHAR.CF.60490760 | WA | Y | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2108127 | 01 | PK | OTHER | 6005060 | 05 | WA | MEDICAID |