Healthcare Provider Details

I. General information

NPI: 1467533687
Provider Name (Legal Business Name): K-C PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 02/15/2022
Certification Date: 02/15/2022
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: 509-773-4555
Mailing address:
  • Phone: 509-773-4344
  • Fax: 509-773-4555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberCF00002121
License Number StateWA

VIII. Authorized Official

Name: JEFFREY SHANE HARRELL
Title or Position: VICE PRESIDENT
Credential: PHARMD
Phone: 509-773-4344