1558714477 NPI number — COSTCO

Table of content: (NPI 1558714477)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558714477 NPI number — COSTCO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COSTCO
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:
PHARNACY
Provider Other Organization Name Type Code:
3
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:
1558714477
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11064 BRANDYWINE LAKE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOYNTON BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33473-4888
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-551-4692
Provider Business Mailing Address Fax Number:
954-972-0368

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1800 W SAMPLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POMPANO BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33064-1324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-972-0313
Provider Business Practice Location Address Fax Number:
954-972-9738
Provider Enumeration Date:
07/15/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WEISLER
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
MARK
Authorized Official Title or Position:
PHARMACIST
Authorized Official Telephone Number:
954-551-4692

Provider Taxonomy Codes

  • Taxonomy code: 1835P2201X , with the licence number:  PS15275 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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