MEDICARE: MENS PHARMACY LLC

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	333600000X	Pharmacy

General Provider Information

NPI Number	:	1790504678
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MENS PHARMACY LLC

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	:	201 E PIONEER AVE
Second Line	:
City	:	MONTESANO
State	:	WA
Zip	:	98563-4514
Country	:	US
Telephone Number	:	360-249-4831
Fax Number	:	360-249-4595

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	JEFFREY HARRELL
Credential	:
Telephone Number	:	360-244-5984

Provider Enumeration Date	:	10/07/2024
Last Update Date	:	10/07/2024

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