Provider Demographics
NPI:1861409880
Name:CHINOOK PHARMACY, INC.
Entity type:Organization
Organization Name:CHINOOK PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:HARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:360-244-5984
Mailing Address - Street 1:PO BOX 2136
Mailing Address - Street 2:
Mailing Address - City:FORKS
Mailing Address - State:WA
Mailing Address - Zip Code:98331-2136
Mailing Address - Country:US
Mailing Address - Phone:360-374-2294
Mailing Address - Fax:360-374-5057
Practice Address - Street 1:11 S FORKS AVE
Practice Address - Street 2:
Practice Address - City:FORKS
Practice Address - State:WA
Practice Address - Zip Code:98331-9006
Practice Address - Country:US
Practice Address - Phone:360-374-2294
Practice Address - Fax:360-374-5057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACF00058860332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9045162Medicaid
WA16470OtherLABOR & INDUSTRIES
WA6090203Medicaid
WA6090203Medicaid