Healthcare Provider Details

I. General information

NPI: 1801169628
Provider Name (Legal Business Name): OKANOGAN VALLEY PROFESSIONAL PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2012
Last Update Date: 08/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 N. 2ND AVE.
OKANOGAN WA
98840
US

IV. Provider business mailing address

PO BOX 1247
OKANOGAN WA
98840-1247
US

V. Phone/Fax

Practice location:
  • Phone: 509-422-9958
  • Fax: 509-422-9998
Mailing address:
  • Phone: 509-422-9958
  • Fax: 509-422-9998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHAR.CF.60427458
License Number StateWA

VIII. Authorized Official

Name: TRENT DANIELSON
Title or Position: OWNER
Credential: PHARMD
Phone: 509-322-6321