1558421529 NPI number — COLUMBIA RIVER PHARMACY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558421529 NPI number — COLUMBIA RIVER PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLUMBIA RIVER PHARMACY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CARLSONS UMATILLA DRUG
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558421529
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1497
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UMATILLA
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97882-1497
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-922-3281
Provider Business Mailing Address Fax Number:
541-922-3760

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
821 6TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UMATILLA
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97882-9513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-922-3281
Provider Business Practice Location Address Fax Number:
541-922-3760
Provider Enumeration Date:
12/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WHITMER
Authorized Official First Name:
HIRAM
Authorized Official Middle Name:
SETH
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
541-481-7212

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: RP0000574 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 148049 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2077643 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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