Provider Demographics
NPI:1104831726
Name:EASTMONT PHARMACY INC
Entity Type:Organization
Organization Name:EASTMONT PHARMACY INC
Other - Org Name:EASTMONT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COOWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLIDAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-884-7254
Mailing Address - Street 1:630 VALLEY MALL PKWY
Mailing Address - Street 2:
Mailing Address - City:E WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98802-4838
Mailing Address - Country:US
Mailing Address - Phone:509-884-7254
Mailing Address - Fax:509-884-4698
Practice Address - Street 1:630 VALLEY MALL PKWY
Practice Address - Street 2:
Practice Address - City:E WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98802-4838
Practice Address - Country:US
Practice Address - Phone:509-884-7254
Practice Address - Fax:509-884-4698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WACF000041843336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4903298OtherNCPDP PROVIDER IDENTIFICATION NUMBER