Provider Demographics
NPI:1437193547
Name:14TH AVENUE PHARMACY INC.
Entity Type:Organization
Organization Name:14TH AVENUE PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:LOUDERBACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-489-1135
Mailing Address - Street 1:8055 O ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-2565
Mailing Address - Country:US
Mailing Address - Phone:402-489-1135
Mailing Address - Fax:
Practice Address - Street 1:1200 N 14TH AVE
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-4192
Practice Address - Country:US
Practice Address - Phone:509-547-8360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy