Healthcare Provider Details

I. General information

NPI: 1942822515
Provider Name (Legal Business Name): WILLAMETTE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2020
Last Update Date: 05/17/2020
Certification Date: 05/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10720 W INDIAN SCHOOL RD STE 53
PHOENIX AZ
85037-5724
US

IV. Provider business mailing address

10720 W INDIAN SCHOOL RD STE 53
PHOENIX AZ
85037-5724
US

V. Phone/Fax

Practice location:
  • Phone: 800-604-3294
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: BUD ADAMS
Title or Position: MANAGER
Credential: PHARMACY MANAGER
Phone: 360-772-9649