1417067109 NPI number — THE BARTELL DRUG CO

Table of content: (NPI 1417067109)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417067109 NPI number — THE BARTELL DRUG CO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE BARTELL DRUG CO
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:
1417067109
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4025 DELRIDGE WAY SW
Provider Second Line Business Mailing Address:
STE 400
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98106-1249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-767-1316
Provider Business Mailing Address Fax Number:
206-767-1397

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3601 6TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98406-5405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-761-1248
Provider Business Practice Location Address Fax Number:
253-761-7462
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KOO
Authorized Official First Name:
PETER
Authorized Official Middle Name:
Authorized Official Title or Position:
SR VP OF PHARMACY
Authorized Official Telephone Number:
206-763-2626

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: CF00056781 , 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: 6024210 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2110926 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0333520057 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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