Basic Information
Provider Information | |||||||||
NPI: | 1437193570 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COLUMBIA VALLEY COMMUNITY HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COLUMBIA VALLEY COMMUNITY HEALTH PHARMACY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 600 ORONDO AVE | ||||||||
Address2: | SUITE 1 | ||||||||
City: | WENATCHEE | ||||||||
State: | WA | ||||||||
PostalCode: | 988012800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5096626000 | ||||||||
FaxNumber: | 5096644590 | ||||||||
Practice Location | |||||||||
Address1: | 600 ORONDO AVE STE 1 | ||||||||
Address2: |   | ||||||||
City: | WENATCHEE | ||||||||
State: | WA | ||||||||
PostalCode: | 988012800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5096643508 | ||||||||
FaxNumber: | 5096644591 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/16/2006 | ||||||||
LastUpdateDate: | 12/31/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | OLSON | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5096643528 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | 601-108-231 | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/31/2019 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | CF00056388 | WA | Y |   | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
ID | Type | State | Issuer | Description | CF00056388 | 01 | WA | COMMUNITY PHARMACY | OTHER | 6022313 | 05 | WA |   | MEDICAID | BC6479542 | 01 |   | DEA LICENSE | OTHER |