Basic Information
| Provider Information | |||||||||
| NPI: | 1528703485 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBIA BASIN HEALTH ASSOCIATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 E COLUMBIA ST | ||||||||
| Address2: | |||||||||
| City: | OTHELLO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993441846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094885256 | ||||||||
| FaxNumber: | 5094889939 | ||||||||
| Practice Location | |||||||||
| Address1: | 1515 E COLUMBIA ST | ||||||||
| Address2: | |||||||||
| City: | OTHELLO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993441846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094885256 | ||||||||
| FaxNumber: | 5094889939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2022 | ||||||||
| LastUpdateDate: | 07/13/2022 | ||||||||
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| AuthorizedOfficialLastName: | GOMEZ | ||||||||
| AuthorizedOfficialFirstName: | NIEVES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5094885256 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 07/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336S0011X | Y | Suppliers | Pharmacy | Specialty Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | PH.CF.61335712 | 01 | WA | DOH LICENSE | OTHER | 1014705 | 05 | WA | MEDICAID |