MEDICARE: WILLIAMS MEDCO INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy	RP-0000585-CS	OR
2	333600000X	Pharmacy	RP0000585CS	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	38-11216	OTHER		NCPDP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639162217
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLIAMS MEDCO INC

Provider Business Mailing Address
First Line	:	916 W EVERGREEN BLVD
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98660
Country	:	US
Telephone Number	:	360-213-2236
Fax Number	:	360-213-2238

Provider Business Practice Location Address
First Line	:	2515 NEWBURG HWY
Second Line	:
City	:	WOODBURN
State	:	OR
Zip	:	97071
Country	:	US
Telephone Number	:	503-981-3591
Fax Number	:	503-982-0566

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JACK L. HOLT
Credential	:	RPH
Telephone Number	:	503-981-3591

Provider Enumeration Date	:	08/29/2005
Last Update Date	:	11/01/2010

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