Provider Demographics
NPI:1700417854
Name:PROSSER SOUTHGATE PHARMACY INC
Entity Type:Organization
Organization Name:PROSSER SOUTHGATE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LATEEF
Authorized Official - Middle Name:A
Authorized Official - Last Name:OLANIYAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, PHARMD
Authorized Official - Phone:509-750-8319
Mailing Address - Street 1:2709 W. BROADWAY AVENUE
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837
Mailing Address - Country:US
Mailing Address - Phone:509-750-8319
Mailing Address - Fax:509-765-4761
Practice Address - Street 1:207 CANYON DRIVE
Practice Address - Street 2:
Practice Address - City:PROSSER
Practice Address - State:WA
Practice Address - Zip Code:99350-1009
Practice Address - Country:US
Practice Address - Phone:509-750-8319
Practice Address - Fax:509-765-4761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy