Healthcare Provider Details

I. General information

NPI: 1184764458
Provider Name (Legal Business Name): NOOKSACK VALLEY DRUG STORE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 02/10/2023
Certification Date: 02/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 E MAIN ST
EVERSON WA
98247-0307
US

IV. Provider business mailing address

PO BOX 307 208 E MAIN ST
EVERSON WA
98247-0307
US

V. Phone/Fax

Practice location:
  • Phone: 360-966-3481
  • Fax: 360-966-3083
Mailing address:
  • Phone: 360-966-3481
  • Fax: 360-966-3083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number
License Number State

VIII. Authorized Official

Name: MRS. MEAGAN KAMMENGA
Title or Position: OWNER
Credential:
Phone: 360-966-3481