Provider Demographics
NPI:1780748889
Name:TIETON VILLAGE DRUG
Entity type:Organization
Organization Name:TIETON VILLAGE DRUG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:LUTHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-966-6850
Mailing Address - Street 1:3708 TIETON DR
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3664
Mailing Address - Country:US
Mailing Address - Phone:509-966-6850
Mailing Address - Fax:509-966-2690
Practice Address - Street 1:3708 TIETON DR
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3664
Practice Address - Country:US
Practice Address - Phone:509-966-6850
Practice Address - Fax:509-966-2690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies