Provider Demographics
NPI:1306857800
Name:CASTLE ROCK PHARMACY INC
Entity Type:Organization
Organization Name:CASTLE ROCK PHARMACY INC
Other - Org Name:CASTLE ROCK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHON
Authorized Official - Middle Name:
Authorized Official - Last Name:RODEBACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-274-8211
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:WA
Mailing Address - Zip Code:98611-0188
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:117 1ST SW
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:WA
Practice Address - Zip Code:98611
Practice Address - Country:US
Practice Address - Phone:360-274-8211
Practice Address - Fax:360-274-7825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WAPHAR.CF.000019753336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2106573OtherPK
WA6166805Medicaid
2106573OtherPK