Provider Demographics
NPI:1992701155
Name:WILLIAM R. COLEMAN
Entity type:Organization
Organization Name:WILLIAM R. COLEMAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:509-877-2707
Mailing Address - Street 1:301 S WAPATO AVE
Mailing Address - Street 2:P.O. BOX 98
Mailing Address - City:WAPATO
Mailing Address - State:WA
Mailing Address - Zip Code:98951-1346
Mailing Address - Country:US
Mailing Address - Phone:509-877-2707
Mailing Address - Fax:509-877-2577
Practice Address - Street 1:301 S WAPATO AVE
Practice Address - Street 2:
Practice Address - City:WAPATO
Practice Address - State:WA
Practice Address - Zip Code:98951-1346
Practice Address - Country:US
Practice Address - Phone:509-877-2707
Practice Address - Fax:509-877-2577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00009443333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6065304Medicaid
WA0731920001Medicare NSC