Provider Demographics
NPI:1003963000
Name:DAVID C WYNECOOP MEMORIAL CLINIC
Entity Type:Organization
Organization Name:DAVID C WYNECOOP MEMORIAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:N
Authorized Official - Last Name:WILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-258-4517
Mailing Address - Street 1:6203 AGENCY LOOP ROAD
Mailing Address - Street 2:
Mailing Address - City:WELLPINIT
Mailing Address - State:WA
Mailing Address - Zip Code:99040-0357
Mailing Address - Country:US
Mailing Address - Phone:509-258-4517
Mailing Address - Fax:509-258-7152
Practice Address - Street 1:6203 AGENCY LOOP ROAD
Practice Address - Street 2:
Practice Address - City:WELLPINIT
Practice Address - State:WA
Practice Address - Zip Code:99040-0357
Practice Address - Country:US
Practice Address - Phone:509-258-4517
Practice Address - Fax:509-258-7152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4926309OtherNCPDP NUMBER
WAPH00052198OtherLICENSE
WAPH00044329OtherLICENSE