Provider Demographics
NPI:1205906385
Name:LJS FURNESS DRUG
Entity type:Organization
Organization Name:LJS FURNESS DRUG
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHCST
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-425-3280
Mailing Address - Street 1:114 PACIFIC AVE S
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-1616
Mailing Address - Country:US
Mailing Address - Phone:360-425-3280
Mailing Address - Fax:360-425-0625
Practice Address - Street 1:114 PACIFIC AVE S
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-1616
Practice Address - Country:US
Practice Address - Phone:360-425-3280
Practice Address - Fax:360-425-0625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X, 3336M0003X, 333600000X
WAPHAR.CF.000568783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6005383Medicaid
2108511OtherPK
2108511OtherPK