Provider Demographics
NPI:1427105030
Name:WASHINGTON STATE UNIVERSITY
Entity type:Organization
Organization Name:WASHINGTON STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:L
Authorized Official - Last Name:HEIMBIGNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:509-335-5742
Mailing Address - Street 1:PO BOX 642302
Mailing Address - Street 2:1125 SE WASHINGTON STREET
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99164-2302
Mailing Address - Country:US
Mailing Address - Phone:509-335-5742
Mailing Address - Fax:509-335-5745
Practice Address - Street 1:1125 SE WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163
Practice Address - Country:US
Practice Address - Phone:509-335-5742
Practice Address - Fax:509-335-5745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACF00562283336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6012942Medicaid
WA4926537OtherNABP
WAFH4454271OtherDEA