1902459100 NPI number — TIETON VILLAGE DRUG INC.

Table of content: (NPI 1902459100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902459100 NPI number — TIETON VILLAGE DRUG INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIETON VILLAGE DRUG INC.
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:
Provider Other Organization Name Type Code:
6
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:
1902459100
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3708 TIETON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YAKIMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98902-3696
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-966-6850
Provider Business Mailing Address Fax Number:
509-966-2690

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10410 E 9TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPOKANE VALLEY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99206-3510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-505-1300
Provider Business Practice Location Address Fax Number:
866-934-0323
Provider Enumeration Date:
07/17/2019

Additional Information

Authorized Official

Authorized Official Last Name:
LUTHER
Authorized Official First Name:
PHIL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
509-961-2103

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4939229 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2146642 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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