1053461103 NPI number — SWANSONS FOOD OF ABERDEEN INC

Table of content: (NPI 1053461103)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053461103 NPI number — SWANSONS FOOD OF ABERDEEN INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SWANSONS FOOD OF ABERDEEN INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SWANSONS OWL PHARMACY
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053461103
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
117 N BOONE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ABERDEEN
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-533-3294
Provider Business Mailing Address Fax Number:
360-533-1832

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
117 N BOONE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ABERDEEN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-533-3294
Provider Business Practice Location Address Fax Number:
360-533-1832
Provider Enumeration Date:
01/11/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
VERNEY
Authorized Official First Name:
JANN
Authorized Official Middle Name:
CAROL
Authorized Official Title or Position:
PHARMACY MANAGER
Authorized Official Telephone Number:
360-533-3294

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  CF00000826 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4915231 . This is a "NABP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6157101 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".