Provider Demographics
NPI:1942203781
Name:WALLA WALLA HOMEMEDICAL INC
Entity Type:Organization
Organization Name:WALLA WALLA HOMEMEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-525-1066
Mailing Address - Street 1:329 S 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-3034
Mailing Address - Country:US
Mailing Address - Phone:509-525-1066
Mailing Address - Fax:509-522-2361
Practice Address - Street 1:329 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-3034
Practice Address - Country:US
Practice Address - Phone:509-525-1066
Practice Address - Fax:509-522-2361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601013167332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9001710Medicaid
OR161646Medicaid
WA9012832Medicaid
WA9012832Medicaid