Basic Information
| Provider Information | |||||||||
| NPI: | 1487105482 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NATIVE PROJECT PHARMACY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1803 W MAXWELL AVE | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992012831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093255502 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1803 W MAXWELL AVE | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992012831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093255502 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2016 | ||||||||
| LastUpdateDate: | 10/14/2016 | ||||||||
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| AuthorizedOfficialLastName: | LODGE | ||||||||
| AuthorizedOfficialFirstName: | TONI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5093255502 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332800000X | 601182805 | WA | N | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy | 3336C0002X | 601182805 | WA | N | Suppliers | Pharmacy | Clinic Pharmacy | 261QF0400X | 601182805 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 2039882 | 05 | WA | MEDICAID |