Provider Demographics
NPI:1184764458
Name:NOOKSACK VALLEY DRUG STORE LLC
Entity type:Organization
Organization Name:NOOKSACK VALLEY DRUG STORE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MEAGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KAMMENGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-966-3481
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:208 E MAIN ST
Mailing Address - City:EVERSON
Mailing Address - State:WA
Mailing Address - Zip Code:98247-0307
Mailing Address - Country:US
Mailing Address - Phone:360-966-3481
Mailing Address - Fax:360-966-3083
Practice Address - Street 1:208 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EVERSON
Practice Address - State:WA
Practice Address - Zip Code:98247-0307
Practice Address - Country:US
Practice Address - Phone:360-966-3481
Practice Address - Fax:360-966-3083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Multi-Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6020663Medicaid
WA4549350001Medicare NSC