Provider Demographics
NPI:1558421529
Name:COLUMBIA RIVER PHARMACY
Entity Type:Organization
Organization Name:COLUMBIA RIVER PHARMACY
Other - Org Name:CARLSONS UMATILLA DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:HIRAM
Authorized Official - Middle Name:SETH
Authorized Official - Last Name:WHITMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-481-7212
Mailing Address - Street 1:PO BOX 1497
Mailing Address - Street 2:
Mailing Address - City:UMATILLA
Mailing Address - State:OR
Mailing Address - Zip Code:97882-1497
Mailing Address - Country:US
Mailing Address - Phone:541-922-3281
Mailing Address - Fax:541-922-3760
Practice Address - Street 1:821 6TH ST
Practice Address - Street 2:
Practice Address - City:UMATILLA
Practice Address - State:OR
Practice Address - Zip Code:97882-9513
Practice Address - Country:US
Practice Address - Phone:541-922-3281
Practice Address - Fax:541-922-3760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ORRP00005743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR148049Medicaid
2077643OtherPK