Provider Demographics
NPI:1417036997
Name:WILLAPA HARBOR PHARMACIES INC
Entity Type:Organization
Organization Name:WILLAPA HARBOR PHARMACIES INC
Other - Org Name:SOUTH BEND PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-875-5757
Mailing Address - Street 1:PO BOX 395
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:WA
Mailing Address - Zip Code:98586-0395
Mailing Address - Country:US
Mailing Address - Phone:360-875-5757
Mailing Address - Fax:360-875-6021
Practice Address - Street 1:101 WILLAPA AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:WA
Practice Address - Zip Code:98586
Practice Address - Country:US
Practice Address - Phone:360-875-5757
Practice Address - Fax:360-875-6021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WACF.600614113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2107430OtherPK
WA6107007Medicaid