Healthcare Provider Details

I. General information

NPI: 1235010794
Provider Name (Legal Business Name): KAYLA RAE HUBER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2025
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 W MAIN ST
GOLDENDALE WA
98620-9589
US

IV. Provider business mailing address

104 W MAIN ST
GOLDENDALE WA
98620-9589
US

V. Phone/Fax

Practice location:
  • Phone: 509-773-4344
  • Fax: 509-773-4526
Mailing address:
  • Phone: 509-773-4344
  • Fax: 509-773-4526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberPH61690922
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPH61690922
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: