Provider Demographics
NPI:1912549254
Name:CHAS SOUTHGATE PHARMACY
Entity Type:Organization
Organization Name:CHAS SOUTHGATE PHARMACY
Other - Org Name:SOUTHGATE RETAIL PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-444-8888
Mailing Address - Street 1:611 N IRON BRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-4932
Mailing Address - Country:US
Mailing Address - Phone:509-444-8888
Mailing Address - Fax:
Practice Address - Street 1:5620 S REGAL ST STE 11
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-7957
Practice Address - Country:US
Practice Address - Phone:509-444-8888
Practice Address - Fax:509-232-0666
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHAS SOUTHGATE PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-08
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2124174Medicaid