=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093144248
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COASTAL PHARMACIES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2013
-----------------------------------------------------
Last Update Date | 03/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 SW ARROW STREET
-----------------------------------------------------
City | WALDPORT
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97394
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-563-6444
-----------------------------------------------------
Fax | 541-563-6448
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 916 W EVERGREEN BLVD
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98660-3035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-213-2236
-----------------------------------------------------
Fax | 360-213-2238
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASST PHARMACY DIRECTOR
-----------------------------------------------------
Name | MS. GINA D GARRISON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 360-213-2236
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | RP0002596CS
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------