Healthcare Provider Details

I. General information

NPI: 1245806785
Provider Name (Legal Business Name): MELODIE D RACICKY PHARMACIST TECHNICIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 06/03/2021
Certification Date: 05/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 BASIN ST SW
EPHRATA WA
98823-1852
US

IV. Provider business mailing address

250 BASIN ST SW
EPHRATA WA
98823-1852
US

V. Phone/Fax

Practice location:
  • Phone: 509-754-3513
  • Fax:
Mailing address:
  • Phone: 509-754-3513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberVA61037827
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: