Provider Demographics
NPI:1700466356
Name:NOOKSACK VALLEY DRUG STORE LLC
Entity Type:Organization
Organization Name:NOOKSACK VALLEY DRUG STORE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:A
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:360-303-5451
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
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:98247-9126
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:2021-04-08
Last Update Date:2021-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6026003Medicaid