MEDICARE: CENTRALIA PHARMACY GROUP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336L0003X	Long Term Care Pharmacy

General Provider Information

NPI Number	:	1720672421
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRALIA PHARMACY GROUP, INC.

Provider Business Mailing Address
First Line	:	PO BOX B
Second Line	:
City	:	ILWACO
State	:	WA
Zip	:	98624-0167
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	417 S TOWER AVE
Second Line	:
City	:	CENTRALIA
State	:	WA
Zip	:	98531-3917
Country	:	US
Telephone Number	:	360-736-5000
Fax Number	:	360-736-9433

Authorized Official
Title or Position	:	OWNER
Name	:	JEFFREY SHANE HARRELL
Credential	:	PHARMD
Telephone Number	:	360-244-5984

Provider Enumeration Date	:	02/23/2021
Last Update Date	:	02/23/2021

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