Organization
PROFESSIONAL MALL PHARMACY INC
Active
Other names
SIDS PROFESSIONAL PHARMACY
Organization subpart
No
Provider details
NPI number
Authorized official
DARCY LINDERMAN (OFFICE MANAGER)
(509) 332-0630
Entity
Organization
Contact information
Practice address
825 SE BISHOP BLVD, STE 301, PULLMAN, WA 99163-5517
(509) 332-4608
(509) 332-3341
Mailing address
825 SE BISHOP BLVD, SUITE 301, PULLMAN, WA 99163-5517
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
CF00001254
WA
3336C0004X
Compounding Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
4328400
—
ID
01
—
4905836
NCPDP PROVIDER IDENTIFICATION NUMBER
—
05
—
6564307
—
WA
Enumeration date
10/31/2006
Last updated
05/05/2015
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