Healthcare Provider Details

I. General information

NPI: 1336686039
Provider Name (Legal Business Name): CENTRALIA PHARMACY GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2017
Last Update Date: 03/31/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 S TOWER AVE
CENTRALIA WA
98531-3917
US

IV. Provider business mailing address

PO BOX B
ILWACO WA
98624-0167
US

V. Phone/Fax

Practice location:
  • Phone: 360-736-5000
  • Fax: 360-736-9433
Mailing address:
  • Phone: 360-244-5984
  • Fax: 888-788-5384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JEFF HARRELL
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 360-244-5984