Provider Demographics
NPI:1427190776
Name:KELSO DRUG CO
Entity Type:Organization
Organization Name:KELSO DRUG CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLINGSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-423-2220
Mailing Address - Street 1:PO BOX 27
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-0002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:204 S PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-1618
Practice Address - Country:US
Practice Address - Phone:360-423-2220
Practice Address - Fax:360-425-1940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACF00002494333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60000632Medicaid
4904199OtherOTHER ID NUMBER-COMMERCIAL NUMBER