NPIMap

Organization Active NPI

Kelley-Ross & Assoc Inc

Doing business as Kelley-Ross Pharmacy at the Polyclinic

  • Pharmacy
  • Seattle, WA
National Provider Identifier
1669517025
Registry record updated Jan 6, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
PharmacyTaxonomy code 333600000X
License
CF00055786 Issued in WA
Legal business name
KELLEY-ROSS & ASSOC INC
Doing business as
Kelley-Ross Pharmacy at the Polyclinic
Practice address
904 7TH Ave
Suite 103
Seattle, WA 98104-1132
Phone
(206) 324-6990
Fax
(206) 329-1849
NPI assigned
Feb 21, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 6, 2021

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

Authorized official

Name
Dr. Ryan D Oftebro, PHARMDNPI 1679560882
Title
President
Phone
(206) 622-3565

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Pharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup: 193200000X MULTI-SPECIALTY GROUP 1835P0018X
Clinical Pharmacology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208U00000X
Clinic/Center 261Q00000X
Pharmacy 333600000X CF00055786 WA Primary

Addresses

Primary practice location

904 7TH Ave
Suite 103
Seattle, WA 98104-1132

Mailing address

904 7TH Ave
Suite 103
Seattle, WA 98104-1132
Phone (206) 324-6990

Other identifiers 2

IdentifierTypeStateIssuer
6019087MedicaidWA
CF00055786OtherWASTATE PHARMACY

Other names 1

  • Kelley-Ross Pharmacy at the Polyclinic Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20071102000148 WA Part B Supplier - Mass Immunization (Roster Biller Only) 1456448703 1 other NPI on this enrollment
Practice locations: Seattle, WA
O20100930099180 WA DME Supplier - Pharmacy 1456448703 Practice locations: Seattle, WA

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Kelley-Ross Assoc Inc6 organizations share this tax ID, including this one

Other organizations with this tax ID 5

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

Locations

400 Pine St
Ste 100
Seattle, WA 98101

2120 S Plum St
Ste C
Seattle, WA 98144
Phone (206) 838-4567

400 E Pine St
Ste 100B
Seattle, WA 98122
Phone (206) 641-7766

Practitioners & affiliated clinicians

Practitioners 15

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 15

NPI Registry JSON

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

{
    "created_epoch": "1172016000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1609891200000",
    "number": "1669517025",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "904 7TH AVE",
            "address_2": "SUITE 103",
            "city": "SEATTLE",
            "state": "WA",
            "postal_code": "981041132",
            "telephone_number": "206-324-6990",
            "fax_number": "206-329-1849"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "904 7TH AVE",
            "address_2": "SUITE 103",
            "city": "SEATTLE",
            "state": "WA",
            "postal_code": "981041132",
            "telephone_number": "206-324-6990",
            "fax_number": "206-329-1849"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KELLEY-ROSS & ASSOC INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-21",
        "last_updated": "2021-01-06",
        "certification_date": "2021-01-06",
        "status": "A",
        "authorized_official_last_name": "OFTEBRO",
        "authorized_official_first_name": "RYAN",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "206-622-3565",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PHARMD"
    },
    "taxonomies": [
        {
            "code": "1835P0018X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pharmacist, Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208U00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Clinical Pharmacology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "WA",
            "license": "CF00055786",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "6019087",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE PHARMACY",
            "identifier": "CF00055786",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Kelley-Ross Pharmacy at the Polyclinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Kelley-Ross Pharmacy at the Polyclinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Seattle, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 6, 2021; 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.