Organization
VIDISA LLC
Active
Other names
Cle Elum Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
VIRGINIA KELLY DON'T CHANGE MY INFO (OWNER/PARTNER)
(509) 322-7097
Entity
Organization
Contact information
Practice address
115 W 1ST ST, CLE ELUM, WA 98922-1515
(509) 852-0123
(509) 852-4567
Mailing address
PO BOX 871, OMAK, WA 98841-0871
(509) 322-7097
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
PHAR.CF.6082533
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2099187
—
WA
01
—
2176385
PK
—
Enumeration date
03/07/2018
Last updated
08/12/2021
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