NPIMap

Organization Active NPI

Tieton Village Drug Inc.

  • Community/Retail Pharmacy
  • Yakima, WA
National Provider Identifier
1659450336
Registry record updated Sep 18, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
CF00056158 Issued in WA
Legal business name
TIETON VILLAGE DRUG INC.
Doing business as
TIETON VILLAGE DRUG
Practice address
3708 Tieton Dr
Yakima, WA 98902-3664
Phone
(509) 966-6850
Fax
(509) 966-2690
NPI assigned
Nov 3, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 18, 2013

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

Authorized official

Name
Ryan Davis
Title
Gen MGR
Phone
(509) 469-3198

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pharmacy 333600000X
Community/Retail Pharmacy 3336C0003X CF00056158 WA Primary

Addresses

Primary practice location

3708 Tieton Dr
Yakima, WA 98902-3664

Mailing address

3708 Tieton Dr
Yakima, WA 98902-3664
Phone (509) 469-3198

Other identifiers 2

IdentifierTypeStateIssuer
2106408OtherPK
6712209MedicaidWA

Other names 1

  • TIETON VILLAGE DRUG Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20090708000599 WA Part B Supplier - Mass Immunization (Roster Biller Only) 4284786096 1 other NPI on this enrollment
Practice locations: Spokane Valley, WA; Yakima, WA
O20100930010723 WA DME Supplier - PharmacyDME Supplier - Medical Supply Company With Registered Pharmacist 4284786096 Practice locations: Yakima, WA

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Tieton Village Drug5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Hermiston Nursing & Rehabilitation CenterHermiston, OR, CCN 385263 Skilled nursing facility Adp of the SNF Nov 1, 2021

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

NPI Registry JSON

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

{
    "created_epoch": "1162512000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1379462400000",
    "number": "1659450336",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3708 TIETON DR",
            "city": "YAKIMA",
            "state": "WA",
            "postal_code": "989023664",
            "telephone_number": "509-469-3198",
            "fax_number": "509-469-3205"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3708 TIETON DR",
            "city": "YAKIMA",
            "state": "WA",
            "postal_code": "989023664",
            "telephone_number": "509-966-6850",
            "fax_number": "509-966-2690"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TIETON VILLAGE DRUG INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-03",
        "last_updated": "2013-09-18",
        "status": "A",
        "authorized_official_last_name": "DAVIS",
        "authorized_official_first_name": "RYAN",
        "authorized_official_title_or_position": "GEN MGR",
        "authorized_official_telephone_number": "509-469-3198"
    },
    "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": "CF00056158",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2106408",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "6712209",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "TIETON VILLAGE DRUG",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Yakima, WA

Sources for this page

Verify at the official NPI Registry.