Provider Demographics
NPI:1427381136
Name:SOUTHGATE PHARMACY LLC
Entity Type:Organization
Organization Name:SOUTHGATE PHARMACY LLC
Other - Org Name:SOUTHGATE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:LATEEF
Authorized Official - Middle Name:AJANI
Authorized Official - Last Name:OLANIYAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:509-765-9332
Mailing Address - Street 1:2709 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-2904
Mailing Address - Country:US
Mailing Address - Phone:509-765-9332
Mailing Address - Fax:509-765-4761
Practice Address - Street 1:2709 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-2904
Practice Address - Country:US
Practice Address - Phone:509-765-9332
Practice Address - Fax:509-765-4761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-14
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
WAPHAR.CF.601188933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2122066OtherPK
WA6032577Medicaid
6343830001Medicare NSC