Healthcare Provider Details

I. General information

NPI: 1902866155
Provider Name (Legal Business Name): COWLITZ PHARMACY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 11/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1244 15TH AVE
LONGVIEW WA
98632-3023
US

IV. Provider business mailing address

916 W EVERGREEN BLVD
VANCOUVER WA
98660-3035
US

V. Phone/Fax

Practice location:
  • Phone: 360-423-3360
  • Fax: 360-423-3364
Mailing address:
  • Phone: 360-213-2236
  • Fax: 360-213-2238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberCF00058295
License Number StateWA

VIII. Authorized Official

Name: MR. WINFIELD F MUFFETT III
Title or Position: OWNER
Credential: RPH
Phone: 360-693-5879