Basic Information
| Provider Information | |||||||||
| NPI: | 1053445809 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GROUP HEALTH COOPERATIVE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | REDMOND MEDICAL CENTER PHARMACY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 12400 E MARGINAL WAY S | ||||||||
| Address2: | |||||||||
| City: | TUKWILA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981682559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092417198 | ||||||||
| FaxNumber: | 5092417628 | ||||||||
| Practice Location | |||||||||
| Address1: | 15809 BEAR CREEK PARKWAY | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | REDMOND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980524370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4258826100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 06/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WESSELIUS | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACY MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4258826152 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GROUP HEALTH COOPERATIVE | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | CF60041218 | WA | N | Suppliers | Pharmacy | Clinic Pharmacy | 333600000X | CF60041218 | WA | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | AG6261692 | 01 | WA | DEA | OTHER | 156111 | 01 | WA | L&I | OTHER | CF60041218 | 01 | WA | WA STATE BOARD OF PHARMACY LICENSE | OTHER | 4915762 | 01 | WA | NCPDP | OTHER |