Basic Information
Provider Information | |||||||||
NPI: | 1477501666 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WALLA WALLA VAMC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WALLA WALLA VAMC PHARMACY | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 94423 | ||||||||
Address2: |   | ||||||||
City: | CLEVELAND | ||||||||
State: | OH | ||||||||
PostalCode: | 441014423 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7023413164 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 77 WAINWRIGHT DR | ||||||||
Address2: |   | ||||||||
City: | WALLA WALLA | ||||||||
State: | WA | ||||||||
PostalCode: | 993623975 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5095255200 | ||||||||
FaxNumber: | 5095276137 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2006 | ||||||||
LastUpdateDate: | 10/24/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | POTTER | ||||||||
AuthorizedOfficialFirstName: | ERIN | ||||||||
AuthorizedOfficialMiddleName: | DENISE | ||||||||
AuthorizedOfficialTitleorPosition: | NPI TEAM MEMBER | ||||||||
AuthorizedOfficialTelephone: | 2023822579 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332100000X |   |   | Y |   | Suppliers | Department of Veterans Affairs (VA) Pharmacy |   |
ID Information
ID | Type | State | Issuer | Description | 4912653 | 01 | WA | NCPDP# | OTHER |