1215930300 NPI number — KIRK'S DRUG, INC

Table of content: (NPI 1215930300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215930300 NPI number — KIRK'S DRUG, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIRK'S DRUG, 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:
Provider Other Organization Name Type Code:
6
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:
1215930300
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6149 MARTIN WAY E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LACEY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98516-5547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-493-8614
Provider Business Mailing Address Fax Number:
360-493-8612

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6906 MARTIN WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98516-5567
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-456-5475
Provider Business Practice Location Address Fax Number:
360-491-2161
Provider Enumeration Date:
05/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WALETICH
Authorized Official First Name:
MARVIN
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
360-694-7377

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BX2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1005114 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9011800 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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