Provider Demographics
NPI:1477006948
Name:JEFFERSON FAMILY PHARMACY INC.
Entity Type:Organization
Organization Name:JEFFERSON FAMILY PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:KOEHMSTEDT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:360-697-5995
Mailing Address - Street 1:2005 E SIMS WAY
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-6905
Mailing Address - Country:US
Mailing Address - Phone:360-385-3005
Mailing Address - Fax:360-385-3880
Practice Address - Street 1:2005 E SIMS WAY
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-6905
Practice Address - Country:US
Practice Address - Phone:360-385-3005
Practice Address - Fax:360-385-3880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-01
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy