Provider Demographics
NPI:1639162217
Name:WILLIAMS MEDCO INC
Entity Type:Organization
Organization Name:WILLIAMS MEDCO INC
Other - Org Name:WILLIAM'S FAIRWAY DRUG #1162
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:503-981-3591
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
Mailing Address - Country:US
Mailing Address - Phone:360-213-2236
Mailing Address - Fax:360-213-2238
Practice Address - Street 1:2515 NEWBURG HWY
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071
Practice Address - Country:US
Practice Address - Phone:503-981-3591
Practice Address - Fax:503-982-0566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-29
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP-0000585-CS333600000X
ORRP0000585CS333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
38-11216OtherNCPDP
OR119680Medicaid
OR119680Medicaid