Provider Demographics
NPI:1033116983
Name:ROCHESTER DRUG
Entity Type:Organization
Organization Name:ROCHESTER DRUG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:360-273-5522
Mailing Address - Street 1:7505 183RD AVE SW
Mailing Address - Street 2:UNIT C
Mailing Address - City:ROCHESTER
Mailing Address - State:WA
Mailing Address - Zip Code:98579
Mailing Address - Country:US
Mailing Address - Phone:360-273-5522
Mailing Address - Fax:360-273-8067
Practice Address - Street 1:7505 183RD AVE SW UNIT C
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:WA
Practice Address - Zip Code:98579-9212
Practice Address - Country:US
Practice Address - Phone:360-273-5522
Practice Address - Fax:360-273-8067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6021091Medicaid
WA9046251Medicaid
WA9046053Medicaid
WA9046251Medicaid
WA=========OtherTAX ID NUMBER