Vidisa LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

PHAR.CF.6082533 Issued in WA

Legal business name

VIDISA LLC

Doing business as

Cle Elum Pharmacy

Practice address

115 W 1St St
Cle Elum, WA 98922-1515

Phone

(509) 852-0123

Fax

(509) 852-4567

NPI assigned

Mar 7, 2018

Last updated

Aug 12, 2021By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Virginia Kelly, DON'T CHANGE MY INFO

Title

Owner/Partner

Phone

(509) 322-7097

Specialties & licenses 2

Addresses

Other identifiers 2

Other names 1

• Cle Elum Pharmacy Doing business as

Medicare fee-for-service enrollment

Enrolled in WA

Enrollment records 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1520380800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1628726400000",
    "number": "1487156121",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 871",
            "city": "OMAK",
            "state": "WA",
            "postal_code": "988410871",
            "telephone_number": "509-322-7097"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "115 W 1ST ST",
            "city": "CLE ELUM",
            "state": "WA",
            "postal_code": "989221515",
            "telephone_number": "509-852-0123",
            "fax_number": "509-852-4567"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "VIDISA LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-03-07",
        "last_updated": "2021-08-12",
        "certification_date": "2021-08-12",
        "status": "A",
        "authorized_official_last_name": "KELLY",
        "authorized_official_first_name": "VIRGINIA",
        "authorized_official_title_or_position": "OWNER/PARTNER",
        "authorized_official_telephone_number": "509-322-7097",
        "authorized_official_credential": "DON'T CHANGE MY INFO"
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "WA",
            "license": "PHAR.CF.6082533",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2176385",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2099187",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Cle Elum Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Cle Elum Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Community/Retail Pharmacy in Cle Elum, WA
• Providers in Cle Elum, WA by specialty
• Community/Retail Pharmacy in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 12, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.