Provider Demographics
NPI:1801927900
Name:SANDPOINT CLINIC PHARMACY INC
Entity type:Organization
Organization Name:SANDPOINT CLINIC PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAFFORN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:425-392-8650
Mailing Address - Street 1:450 NW GILMAN BLVD
Mailing Address - Street 2:STE 107
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-2483
Mailing Address - Country:US
Mailing Address - Phone:425-392-8650
Mailing Address - Fax:425-391-8624
Practice Address - Street 1:450 NW GILMAN BLVD
Practice Address - Street 2:STE 107
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2483
Practice Address - Country:US
Practice Address - Phone:425-392-8650
Practice Address - Fax:425-391-8624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2010-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X, 3336C0004X
WACF000035643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4919330OtherNCPDP PROVIDER IDENTIFICATION NUMBER
WA6006934Medicaid