Provider Demographics
NPI:1902866155
Name:COWLITZ PHARMACY INC.
Entity Type:Organization
Organization Name:COWLITZ PHARMACY INC.
Other - Org Name:OLYMPIC DRUG #1158
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WINFIELD
Authorized Official - Middle Name:F
Authorized Official - Last Name:MUFFETT
Authorized Official - Suffix:III
Authorized Official - Credentials:RPH
Authorized Official - Phone:360-693-5879
Mailing Address - Street 1:916 W EVERGREEN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-3035
Mailing Address - Country:US
Mailing Address - Phone:360-213-2236
Mailing Address - Fax:360-213-2238
Practice Address - Street 1:1244 15TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3023
Practice Address - Country:US
Practice Address - Phone:360-423-3360
Practice Address - Fax:360-423-3364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACF00058295333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6028435Medicaid
4904579OtherNCPDP
WA8855770Medicare PIN