Healthcare Provider Details

I. General information

NPI: 1689702326
Provider Name (Legal Business Name): ODESSA DRUGS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 W. 1ST AVE.
ODESSA WA
99159-0189
US

IV. Provider business mailing address

19 W. 1ST AVE. PO BOX 189
ODESSA WA
99159-0189
US

V. Phone/Fax

Practice location:
  • Phone: 509-982-2541
  • Fax: 509-982-2660
Mailing address:
  • Phone: 509-982-2541
  • Fax: 509-982-2660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberCF00004908
License Number StateWA

VIII. Authorized Official

Name: MR. TED J BRUYA
Title or Position: OWNER
Credential: RPH
Phone: 509-982-2541