Provider Demographics
NPI:1245300797
Name:CLARKSTON HEIGHTS PHARMACY
Entity type:Organization
Organization Name:CLARKSTON HEIGHTS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-882-5536
Mailing Address - Street 1:2119 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-1406
Mailing Address - Country:US
Mailing Address - Phone:509-758-3376
Mailing Address - Fax:509-758-3377
Practice Address - Street 1:2119 5TH AVE
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-1406
Practice Address - Country:US
Practice Address - Phone:509-758-3376
Practice Address - Fax:509-758-3377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6096606Medicaid