Provider Demographics
NPI:1659450336
Name:TIETON VILLAGE DRUG INC.
Entity Type:Organization
Organization Name:TIETON VILLAGE DRUG INC.
Other - Org Name:TIETON VILLAGE DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GEN MGR
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-469-3198
Mailing Address - Street 1:3708 TIETON DR
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3664
Mailing Address - Country:US
Mailing Address - Phone:509-469-3198
Mailing Address - Fax:509-469-3205
Practice Address - Street 1:3708 TIETON DR
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3664
Practice Address - Country:US
Practice Address - Phone:509-966-6850
Practice Address - Fax:509-966-2690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WACF000561583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2106408OtherPK
WA6712209Medicaid
1266020001Medicare NSC