1568912004 NPI number — HIMERX PHARMACY LLC

Table of content: (NPI 1568912004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568912004 NPI number — HIMERX PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HIMERX PHARMACY LLC
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:
HIMERX PHARMACY
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:
1568912004
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3901 NE 4TH ST STE 102A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RENTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98056-4100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-738-1262
Provider Business Mailing Address Fax Number:
425-738-1263

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3901 NE 4TH ST STE 102A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RENTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98056-4100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-738-1262
Provider Business Practice Location Address Fax Number:
425-738-1263
Provider Enumeration Date:
10/08/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GUTIERREZ
Authorized Official First Name:
PINKY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER, PIC, AO
Authorized Official Telephone Number:
425-738-1262

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: PHARCF60679042 , 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: 2070664 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2164573 . This is a "PK" identifier . This identifiers is of the category "OTHER".