Provider Demographics
NPI:1144356494
Name:NORTHWEST PHARMACY SERVICES INC
Entity type:Organization
Organization Name:NORTHWEST PHARMACY SERVICES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:WIL
Authorized Official - Middle Name:O
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:208-875-1212
Mailing Address - Street 1:PO BOX 657
Mailing Address - Street 2:
Mailing Address - City:POTLATCH
Mailing Address - State:ID
Mailing Address - Zip Code:83855-0657
Mailing Address - Country:US
Mailing Address - Phone:208-875-1212
Mailing Address - Fax:208-875-0859
Practice Address - Street 1:210 6TH ST
Practice Address - Street 2:
Practice Address - City:POTLATCH
Practice Address - State:ID
Practice Address - Zip Code:83855-9700
Practice Address - Country:US
Practice Address - Phone:208-875-1212
Practice Address - Fax:208-875-0859
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST PHARMACY SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-23
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QI0500X, 291U00000X, 3336S0011X, 3336C0003X
ID814CP333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No291U00000XLaboratoriesClinical Medical Laboratory
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805885600Medicaid
ID8G734OtherBLUE CROSS OF IDAHO
ID805885600Medicaid
ID805885600Medicaid
ID0181730002Medicare NSC