Basic Information
| Provider Information | |||||||||
| NPI: | 1518406529 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | YAKIMA VALLEY FARM WORKERS CLINIC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LANCASTER FAMILY HEALTH CENTER AT LANCASTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 255 LANCASTER DR NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973015155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035768400 | ||||||||
| FaxNumber: | 5035818281 | ||||||||
| Practice Location | |||||||||
| Address1: | 255 LANCASTER DR NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973015155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035768400 | ||||||||
| FaxNumber: | 5035818283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2017 | ||||||||
| LastUpdateDate: | 02/23/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FOX | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR DIRECTOR PHARMACY | ||||||||
| AuthorizedOfficialTelephone: | 5098656175 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | N | Suppliers | Pharmacy | Clinic Pharmacy | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 333600000X | RP-0003226-CS | OR | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2166549 | 01 | PK | OTHER |