Provider Demographics
NPI:1093818130
Name:DEMAREST INC
Entity type:Organization
Organization Name:DEMAREST INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, PIC
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:DEMAREST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-496-5902
Mailing Address - Street 1:PO BOX 1139
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:WA
Mailing Address - Zip Code:98356-0020
Mailing Address - Country:US
Mailing Address - Phone:360-496-5902
Mailing Address - Fax:360-496-3215
Practice Address - Street 1:100 WESTLAKE AVE
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:WA
Practice Address - Zip Code:98356
Practice Address - Country:US
Practice Address - Phone:360-496-5902
Practice Address - Fax:360-496-3215
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEMAREST, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-06
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
WAPHAR.CF.000560173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1042842Medicaid
2106834OtherPK
WA6077507Medicaid