Provider Demographics
NPI:1073604039
Name:YAKIMA VALLEY FARM WORKERS CLINIC
Entity Type:Organization
Organization Name:YAKIMA VALLEY FARM WORKERS CLINIC
Other - Org Name:YAKIMA VALLEY FARM WORKERS CLINIC - GRANDVIEW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-865-6175
Mailing Address - Street 1:2601 COMMERCE LN
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98901-5801
Mailing Address - Country:US
Mailing Address - Phone:509-865-6175
Mailing Address - Fax:509-865-0840
Practice Address - Street 1:1000 WALLACE WAY
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:WA
Practice Address - Zip Code:98930-8805
Practice Address - Country:US
Practice Address - Phone:509-882-3977
Practice Address - Fax:509-882-2966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACF000559223336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6008940Medicaid
WA4915558OtherNCPDP