Provider Demographics
NPI:1891853925
Name:ZILLAH DRUG STORE INC
Entity Type:Organization
Organization Name:ZILLAH DRUG STORE INC
Other - Org Name:ZILLAH DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PRES
Authorized Official - Prefix:
Authorized Official - First Name:LLOYD
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-829-5691
Mailing Address - Street 1:PO BOX 565
Mailing Address - Street 2:
Mailing Address - City:ZILLAH
Mailing Address - State:WA
Mailing Address - Zip Code:98953-0565
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:607 1ST AVE
Practice Address - Street 2:
Practice Address - City:ZILLAH
Practice Address - State:WA
Practice Address - Zip Code:98953-0565
Practice Address - Country:US
Practice Address - Phone:509-829-5691
Practice Address - Fax:509-829-5691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACF00005195333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4910534OtherOTHER ID NUMBER-COMMERCIAL NUMBER
WA6020598Medicaid
WA6020598Medicaid