Healthcare Provider Details

I. General information

NPI: 1720672421
Provider Name (Legal Business Name): CENTRALIA PHARMACY GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2021
Last Update Date: 02/23/2021
Certification Date: 02/23/2021
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:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY SHANE HARRELL
Title or Position: OWNER
Credential: PHARMD
Phone: 360-244-5984