NPIMap

Organization Active NPI

KSR Health Care LLC

  • Clinic Pharmacy
  • Sultan, WA
National Provider Identifier
1093274458
Registry record updated Mar 10, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic PharmacyTaxonomy code 3336C0002X
Legal business name
KSR HEALTH CARE LLC
Practice address
31111 US-2
Sultan, WA 98294
Phone
(360) 953-5250
Fax
(360) 294-8529
NPI assigned
Mar 15, 2019
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 10, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Simeon Roth, PHARMDNPI 1275047599
Title
Pharmacy Manager
Phone
(360) 953-5250

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Pharmacy 333600000X
Clinic Pharmacy 3336C0002X Primary
Community/Retail Pharmacy 3336C0003X

Addresses

Primary practice location

31111 US-2
Sultan, WA 98294

Mailing address

PO Box 90
Sultan, WA 98294-0090
Phone (360) 953-5250

Other identifiers 1

IdentifierTypeStateIssuer
2132773MedicaidWA

Other names 1

  • Invara Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20191210003585 WA Part B Supplier - Pharmacy 9234562992 Practice locations: Sultan, WA
O20221122001380 WA Part B Supplier - Mass Immunization (Roster Biller Only) 9234562992 Practice locations: Sultan, WA

National Provider Directory

National Provider Directory
Tax ID family
Invara3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1552608000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1646870400000",
    "number": "1093274458",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 90",
            "city": "SULTAN",
            "state": "WA",
            "postal_code": "982940090",
            "telephone_number": "360-953-5250",
            "fax_number": "360-294-8529"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "31111 US-2",
            "city": "SULTAN",
            "state": "WA",
            "postal_code": "98294",
            "telephone_number": "360-953-5250",
            "fax_number": "360-294-8529"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KSR HEALTH CARE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-03-15",
        "last_updated": "2022-03-10",
        "certification_date": "2022-03-10",
        "status": "A",
        "authorized_official_last_name": "ROTH",
        "authorized_official_first_name": "SIMEON",
        "authorized_official_title_or_position": "PHARMACY MANAGER",
        "authorized_official_telephone_number": "360-953-5250",
        "authorized_official_credential": "PHARMD"
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0002X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Clinic Pharmacy",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2132773",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Invara",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Invara",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Sultan, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 10, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.