MEDICARE: TIETON VILLAGE DRUGS 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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	CF00058481	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2108645	OTHER		PK

General Provider Information

NPI Number	:	1831110808
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIETON VILLAGE DRUGS INC

Provider Business Mailing Address
First Line	:	3708 TIETON DR
Second Line	:
City	:	YAKIMA
State	:	WA
Zip	:	98902-3664
Country	:	US
Telephone Number	:	509-469-3198
Fax Number	:	509-469-3205

Provider Business Practice Location Address
First Line	:	4040 TERRACE HEIGHTS DR
Second Line	:	STE 120
City	:	YAKIMA
State	:	WA
Zip	:	98901-1424
Country	:	US
Telephone Number	:	509-248-3311
Fax Number	:	509-248-3322

Authorized Official
Title or Position	:	GM
Name	:	RYAN DAVIS
Credential	:
Telephone Number	:	509-469-3198

Provider Enumeration Date	:	07/22/2006
Last Update Date	:	09/17/2013

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Directions to “TIETON VILLAGE DRUGS INC ” Practice Location

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