Provider Demographics
NPI:1144333469
Name:WESTERN PHARMACY GROUP LLC
Entity type:Organization
Organization Name:WESTERN PHARMACY GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FARIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-220-4818
Mailing Address - Street 1:851 COHO WAY STE 312
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-2066
Mailing Address - Country:US
Mailing Address - Phone:360-685-4270
Mailing Address - Fax:
Practice Address - Street 1:340 4TH AVE
Practice Address - Street 2:STE 1
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-3813
Practice Address - Country:US
Practice Address - Phone:619-422-9291
Practice Address - Fax:619-422-3607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
CA559073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No333600000XSuppliersPharmacyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2175987OtherPK
CAPHA350510Medicaid
CAPHY35051OtherPHARMACY LICENSE
CAPHA350510Medicaid