Provider Demographics
NPI:1184755282
Name:ANCILLARY MEDICAL SERVICES INC
Entity type:Organization
Organization Name:ANCILLARY MEDICAL SERVICES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MGR CEO AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MOULTRAY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:360-336-2102
Mailing Address - Street 1:117 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-2859
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:117 N 1ST ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-2859
Practice Address - Country:US
Practice Address - Phone:360-336-2102
Practice Address - Fax:360-336-2103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WACF000022923336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4915750OtherOTHER ID NUMBER-COMMERCIAL NUMBER
WA6139703Medicaid
4915750OtherOTHER ID NUMBER