Provider Demographics
NPI:1417528282
Name:CHINOOK PHARMACY CLINICAL
Entity Type:Organization
Organization Name:CHINOOK PHARMACY CLINICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/RPH
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:360-374-2294
Mailing Address - Street 1:PO BOX 2136
Mailing Address - Street 2:
Mailing Address - City:FORKS
Mailing Address - State:WA
Mailing Address - Zip Code:98331-2136
Mailing Address - Country:US
Mailing Address - Phone:360-374-2294
Mailing Address - Fax:360-374-5057
Practice Address - Street 1:11 S FORKS AVE STE A
Practice Address - Street 2:
Practice Address - City:FORKS
Practice Address - State:WA
Practice Address - Zip Code:98331-9006
Practice Address - Country:US
Practice Address - Phone:360-374-2294
Practice Address - Fax:360-374-5057
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHINOOK PHARMACY INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-07-02
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty