Provider Demographics
NPI:1497715270
Name:CUTTERS HI-SCHOOL PHARMACY
Entity Type:Organization
Organization Name:CUTTERS HI-SCHOOL PHARMACY
Other - Org Name:CUTTER'S HI-SCHOOL PHARMACY #1167
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:503-829-9111
Mailing Address - Street 1:916 W EVERGREEN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-3035
Mailing Address - Country:US
Mailing Address - Phone:360-213-2236
Mailing Address - Fax:360-213-2238
Practice Address - Street 1:103 ROBBINS ST
Practice Address - Street 2:
Practice Address - City:MOLALLA
Practice Address - State:OR
Practice Address - Zip Code:97038
Practice Address - Country:US
Practice Address - Phone:503-829-9111
Practice Address - Fax:503-829-4884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-24
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP0000637CS333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3802887OtherNCPDP
OR004205Medicaid
3802887OtherNCPDP