Provider Demographics
NPI:1124063367
Name:VANCOUVER CLINIC INC
Entity type:Organization
Organization Name:VANCOUVER CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:MORROW
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:360-397-3880
Mailing Address - Street 1:2525 NE 139TH ST
Mailing Address - Street 2:PHARMACY SUITE 160
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-2719
Mailing Address - Country:US
Mailing Address - Phone:360-397-2880
Mailing Address - Fax:360-604-1794
Practice Address - Street 1:2525 NE 139TH ST
Practice Address - Street 2:SUITE 160
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2719
Practice Address - Country:US
Practice Address - Phone:360-397-2880
Practice Address - Fax:360-604-1794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
WAPHARCF000585593336C0003X, 3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6029078Medicaid
2108657OtherPK