Healthcare Provider Details

I. General information

NPI: 1710091608
Provider Name (Legal Business Name): 14TH AVENUE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N 14TH AVE STE 100
PASCO WA
99301-4182
US

IV. Provider business mailing address

8055 O ST STE 201 LOUDABACK PHARMACIES
LINCOLN NE
68510
US

V. Phone/Fax

Practice location:
  • Phone: 509-547-8360
  • Fax: 509-547-7571
Mailing address:
  • Phone: 402-489-1135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberCF00058660
License Number StateWA

VIII. Authorized Official

Name: SCOTT LOUDERBACK
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 402-489-1135