Healthcare Provider Details

I. General information

NPI: 1205906385
Provider Name (Legal Business Name): LJS FURNESS DRUG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 04/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 PACIFIC AVE S
KELSO WA
98626-1616
US

IV. Provider business mailing address

114 PACIFIC AVE S
KELSO WA
98626-1616
US

V. Phone/Fax

Practice location:
  • Phone: 360-425-3280
  • Fax: 360-425-0625
Mailing address:
  • Phone: 360-425-3280
  • Fax: 360-425-0625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHAR.CF.00056878
License Number StateWA

VIII. Authorized Official

Name: LAWRENCE SCHMIDT
Title or Position: OWNER PHCST
Credential:
Phone: 360-425-3280