Provider Demographics
NPI:1598229809
Name:CLEARWATER CANYON PHARMACY, LLC
Entity Type:Organization
Organization Name:CLEARWATER CANYON PHARMACY, LLC
Other - Org Name:CLEARWATER CANYON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:POTTENGER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:208-476-0110
Mailing Address - Street 1:523 THAIN RD
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-5530
Mailing Address - Country:US
Mailing Address - Phone:208-743-5515
Mailing Address - Fax:208-743-0333
Practice Address - Street 1:13020 US-12
Practice Address - Street 2:
Practice Address - City:OROFINO
Practice Address - State:ID
Practice Address - Zip Code:83544
Practice Address - Country:US
Practice Address - Phone:208-476-0110
Practice Address - Fax:208-476-0115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-31
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy