Provider Demographics
NPI:1275664377
Name:BATTLE GROUND PHARMACY INC
Entity Type:Organization
Organization Name:BATTLE GROUND PHARMACY INC
Other - Org Name:BATTLE GROUND PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:E DARRELL
Authorized Official - Middle Name:
Authorized Official - Last Name:RAFFERTY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:360-687-3128
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-0489
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:717 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-4479
Practice Address - Country:US
Practice Address - Phone:360-687-3128
Practice Address - Fax:360-687-3129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WACF000018293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6018105Medicaid
4901078OtherNCPDP PROVIDER IDENTIFICATION NUMBER
4901078OtherNCPDP PROVIDER IDENTIFICATION NUMBER