Provider Demographics
NPI:1801169628
Name:OKANOGAN VALLEY PROFESSIONAL PHARMACY LLC
Entity type:Organization
Organization Name:OKANOGAN VALLEY PROFESSIONAL PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIELSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:509-322-6321
Mailing Address - Street 1:PO BOX 1247
Mailing Address - Street 2:
Mailing Address - City:OKANOGAN
Mailing Address - State:WA
Mailing Address - Zip Code:98840-1247
Mailing Address - Country:US
Mailing Address - Phone:509-422-9958
Mailing Address - Fax:509-422-9998
Practice Address - Street 1:236 N. 2ND AVE.
Practice Address - Street 2:
Practice Address - City:OKANOGAN
Practice Address - State:WA
Practice Address - Zip Code:98840
Practice Address - Country:US
Practice Address - Phone:509-422-9958
Practice Address - Fax:509-422-9998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-10
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPHAR.CF.604274583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2142898OtherPK
WA2035201Medicaid