Provider Demographics
NPI:1861423717
Name:COLUMBIA RIVER PHARMACY
Entity type:Organization
Organization Name:COLUMBIA RIVER PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRIKSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:509-943-9173
Mailing Address - Street 1:1906 GEORGE WASHINGTON WAY
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99354-2308
Mailing Address - Country:US
Mailing Address - Phone:509-943-9173
Mailing Address - Fax:509-946-1122
Practice Address - Street 1:1906 GEORGE WASHINGTON WAY
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99354-2308
Practice Address - Country:US
Practice Address - Phone:509-943-9173
Practice Address - Fax:509-946-1122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
WAPHAR.CF.601768193336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2106368OtherPK
WA6143903Medicaid