Provider Demographics
NPI:1689702326
Name:ODESSA DRUGS
Entity Type:Organization
Organization Name:ODESSA DRUGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TED
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRUYA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:509-982-2541
Mailing Address - Street 1:19 W. 1ST AVE.
Mailing Address - Street 2:PO BOX 189
Mailing Address - City:ODESSA
Mailing Address - State:WA
Mailing Address - Zip Code:99159-0189
Mailing Address - Country:US
Mailing Address - Phone:509-982-2541
Mailing Address - Fax:509-982-2660
Practice Address - Street 1:19 W. 1ST AVE.
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:WA
Practice Address - Zip Code:99159-0189
Practice Address - Country:US
Practice Address - Phone:509-982-2541
Practice Address - Fax:509-982-2660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACF000049083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0051984OtherWASHINGTON L&I NUMBER
WA6014088Medicaid
WA6014088Medicaid