Basic Information
Provider Information | |||||||||
NPI: | 1699140368 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEALTHPOINT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HEALTHPOINT AUBURN NORTH PHARMACY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 955 POWELL AVE SW | ||||||||
Address2: |   | ||||||||
City: | RENTON | ||||||||
State: | WA | ||||||||
PostalCode: | 980572908 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4252771311 | ||||||||
FaxNumber: | 4252030977 | ||||||||
Practice Location | |||||||||
Address1: | 923 AUBURN WAY N | ||||||||
Address2: |   | ||||||||
City: | AUBURN | ||||||||
State: | WA | ||||||||
PostalCode: | 980024117 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8772330246 | ||||||||
FaxNumber: | 2538042514 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/07/2015 | ||||||||
LastUpdateDate: | 03/09/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WILKINSON | ||||||||
AuthorizedOfficialFirstName: | DEBRA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | COO | ||||||||
AuthorizedOfficialTelephone: | 4252030444 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X |   |   | N |   | Suppliers | Pharmacy |   | 3336C0003X | PHAR.CF.60616167 | WA | Y |   | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 2057171 | 05 | WA |   | MEDICAID | 2157683 | 01 |   | PK | OTHER |