Organization
SOUTHGATE PHARMACY LLC
Active
Other names
Southgate Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
MR. LATEEF AJANI OLANIYAN PHARM D (OWNER/PHARMACIST)
(509) 765-9332
Entity
Organization
Contact information
Practice address
2709 W BROADWAY AVE, MOSES LAKE, WA 98837-2904
(509) 765-9332
(509) 765-4761
Mailing address
2709 W BROADWAY AVE, MOSES LAKE, WA 98837-2904
(509) 765-9332
(509) 765-4761
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
PHAR.CF.60118893
WA
3336L0003X
Long Term Care Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2122066
PK
—
05
—
6032577
—
WA
Enumeration date
09/14/2009
Last updated
10/23/2019
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