Provider Demographics
NPI:1629028378
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:PHARM D
Authorized Official - Phone:402-489-1135
Mailing Address - Street 1:8055 O ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-2564
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:SUITE 100
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-4182
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:2006-05-11
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACF000579823336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6005128Medicaid
WA6005128Medicaid
WA8807619Medicare PIN