Provider Demographics
NPI:1326142373
Name:HALCYON RX INC
Entity Type:Organization
Organization Name:HALCYON RX INC
Other - Org Name:MEDICINE MAN LIBERTY LAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:AMINI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:509-755-3333
Mailing Address - Street 1:23801 E APPLEWAY AVE
Mailing Address - Street 2:STE 260B
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-9687
Mailing Address - Country:US
Mailing Address - Phone:509-755-3333
Mailing Address - Fax:509-755-3337
Practice Address - Street 1:23801 E APPLEWAY AVE
Practice Address - Street 2:STE 260B
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-9687
Practice Address - Country:US
Practice Address - Phone:509-755-3333
Practice Address - Fax:509-755-3337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAFL0341254332B00000X, 3336C0004X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6024178Medicaid
4931463OtherOTHER ID NUMBER-COMMERCIAL NUMBER
WA6024178Medicaid