Provider Demographics
NPI:1710046180
Name:TEKOA RX LLC
Entity Type:Organization
Organization Name:TEKOA RX LLC
Other - Org Name:TEKOA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:LORRAINE
Authorized Official - Last Name:SPERBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-284-4205
Mailing Address - Street 1:PO BOX 808
Mailing Address - Street 2:
Mailing Address - City:TEKOA
Mailing Address - State:WA
Mailing Address - Zip Code:99033
Mailing Address - Country:US
Mailing Address - Phone:509-284-4205
Mailing Address - Fax:509-284-3076
Practice Address - Street 1:124 N CROSBY ST
Practice Address - Street 2:
Practice Address - City:TEKOA
Practice Address - State:WA
Practice Address - Zip Code:99033
Practice Address - Country:US
Practice Address - Phone:509-284-4205
Practice Address - Fax:509-284-3076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 333600000X
WAPHAR.CF.000564263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2110562OtherPK
WA6022479Medicaid
1283280001Medicare NSC