Healthcare Provider Details

I. General information

NPI: 1699764399
Provider Name (Legal Business Name): GRANITE DRUGS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 12/23/2019
Certification Date: 12/23/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 E STANLEY ST # A
GRANITE FALLS WA
98252-8480
US

IV. Provider business mailing address

207 E STANLEY ST STE A
GRANITE FALLS WA
98252-8480
US

V. Phone/Fax

Practice location:
  • Phone: 360-691-7778
  • Fax: 360-691-4458
Mailing address:
  • Phone: 360-691-7778
  • Fax: 360-691-4458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberCF00057675
License Number StateWA

VIII. Authorized Official

Name: KARI VANDERHOUWEN
Title or Position: MANAGING MEMBER
Credential:
Phone: 206-915-7888