Basic Information
| Provider Information | |||||||||
| NPI: | 1750411310 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAVID C WYNECOOP MEMORIAL CLINIC PHARMACY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WELLPINIT SERVICE UNIT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | AGENCY SQUARE | ||||||||
| Address2: | PO BOX 357 | ||||||||
| City: | WELLPINIT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092584517 | ||||||||
| FaxNumber: | 5092587152 | ||||||||
| Practice Location | |||||||||
| Address1: | AGENCY SQUARE | ||||||||
| Address2: | |||||||||
| City: | WELLPINIT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092584517 | ||||||||
| FaxNumber: | 5092587152 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BATTESE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AREA BUSINESS OFFICE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 5033267277 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332800000X | Y | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 4926309 | 01 | NCPDP NUMBER | OTHER | 6021166 | 05 | WA | MEDICAID | AW5043839 | 01 | PHARMACY DEA NUMBER | OTHER |