Healthcare Provider Details

I. General information

NPI: 1588675086
Provider Name (Legal Business Name): HEDDENS PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 01/04/2022
Certification Date: 01/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 SUSSEX AVE W
TENINO WA
98589-9327
US

IV. Provider business mailing address

PO BOX 4008
TENINO WA
98589-4008
US

V. Phone/Fax

Practice location:
  • Phone: 360-264-2575
  • Fax: 360-264-5039
Mailing address:
  • Phone: 360-264-2575
  • Fax: 360-264-5039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHAR.CF00004786
License Number StateWA

VIII. Authorized Official

Name: JEFFREY SHANE HARRELL
Title or Position: VICE PRESIDENT
Credential: PHARMD
Phone: 360-264-2575