Basic Information
| Provider Information | |||||||||
| NPI: | 1750786356 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LATAH COMMUNITY HEALTH PHARMACY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LATAH HEALTH PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 N IRON BRIDGE WAY | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992024932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094448888 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 803 S MAIN ST STE 120 | ||||||||
| Address2: | |||||||||
| City: | MOSCOW | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838433043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088488312 | ||||||||
| FaxNumber: | 2088825587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2014 | ||||||||
| LastUpdateDate: | 08/21/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | AARON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5094448888 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0002X | 37042RP | ID | Y | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1750786356 | 05 | ID | MEDICAID | 2148393 | 01 | PK | OTHER | 2073987 | 05 | WA | MEDICAID |