Provider Demographics
NPI:1801901855
Name:GODFREY'S PHARMACY
Entity type:Organization
Organization Name:GODFREY'S PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ART
Authorized Official - Middle Name:
Authorized Official - Last Name:GODFREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-673-2600
Mailing Address - Street 1:PO BOX 219
Mailing Address - Street 2:
Mailing Address - City:KALAMA
Mailing Address - State:WA
Mailing Address - Zip Code:98625-0200
Mailing Address - Country:US
Mailing Address - Phone:360-673-2600
Mailing Address - Fax:360-673-2601
Practice Address - Street 1:270 N 1ST ST
Practice Address - Street 2:
Practice Address - City:KALAMA
Practice Address - State:WA
Practice Address - Zip Code:98625-9100
Practice Address - Country:US
Practice Address - Phone:360-673-2600
Practice Address - Fax:360-673-2601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WAPHAR.CF.000018313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6052302Medicaid
2106791OtherPK