Provider Demographics
NPI:1902459100
Name:TIETON VILLAGE DRUG INC.
Entity Type:Organization
Organization Name:TIETON VILLAGE DRUG INC.
Other - Org Name:VILLAGE PHARMACY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHIL
Authorized Official - Middle Name:
Authorized Official - Last Name:LUTHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-961-2103
Mailing Address - Street 1:3708 TIETON DR
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3696
Mailing Address - Country:US
Mailing Address - Phone:509-966-6850
Mailing Address - Fax:509-966-2690
Practice Address - Street 1:10410 E 9TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-3510
Practice Address - Country:US
Practice Address - Phone:509-505-1300
Practice Address - Fax:866-934-0323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-17
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4939229OtherNCPDP
WA2146642Medicaid