Provider Demographics
NPI:1730242421
Name:WALLOWA PHARMACY
Entity type:Organization
Organization Name:WALLOWA PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:541-886-2361
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:WALLOWA
Mailing Address - State:OR
Mailing Address - Zip Code:97885
Mailing Address - Country:US
Mailing Address - Phone:541-886-2361
Mailing Address - Fax:541-886-6801
Practice Address - Street 1:207 EAST 1ST ST.
Practice Address - Street 2:
Practice Address - City:WALLOWA
Practice Address - State:OR
Practice Address - Zip Code:97885
Practice Address - Country:US
Practice Address - Phone:541-886-2361
Practice Address - Fax:541-886-6801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP0000584CS3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR179317Medicaid
OR0963090001Medicare NSC