Healthcare Provider Details

I. General information

NPI: 1215948716
Provider Name (Legal Business Name): TICK KLOCK DRUG LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 S MAIN ST
COLFAX WA
99111-1803
US

IV. Provider business mailing address

PO BOX 189
COLFAX WA
99111-0189
US

V. Phone/Fax

Practice location:
  • Phone: 509-397-2111
  • Fax: 509-397-4947
Mailing address:
  • Phone: 509-397-2111
  • Fax:

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 NumberCF00000865
License Number StateWA

VIII. Authorized Official

Name: NATHAN JOHNSON
Title or Position: OWNER/ PHARMACIST
Credential: PHARMD
Phone: 509-397-2111