Provider Demographics
NPI:1316026297
Name:CHENEY OWL PHARMACY INC
Entity Type:Organization
Organization Name:CHENEY OWL PHARMACY INC
Other - Org Name:MEDICAL LAKE OWL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOYKE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:509-235-8441
Mailing Address - Street 1:PO BOX 638
Mailing Address - Street 2:
Mailing Address - City:MEDICAL LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99022-0638
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:123 E LAKE ST
Practice Address - Street 2:
Practice Address - City:MEDICAL LAKE
Practice Address - State:WA
Practice Address - Zip Code:99022
Practice Address - Country:US
Practice Address - Phone:509-299-5113
Practice Address - Fax:509-299-9125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WAPHARCF000018763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2107931OtherPK
WA6067201Medicaid