Provider Demographics
NPI:1073615472
Name:COSTCO WHOLESALE CORPORATION
Entity Type:Organization
Organization Name:COSTCO WHOLESALE CORPORATION
Other - Org Name:COSTCO PHARMACY #475
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AVP PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTROMONICA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-313-2892
Mailing Address - Street 1:PO BOX 34300
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1300
Mailing Address - Country:US
Mailing Address - Phone:425-313-6670
Mailing Address - Fax:425-313-6595
Practice Address - Street 1:1600 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-1206
Practice Address - Country:US
Practice Address - Phone:650-757-3002
Practice Address - Fax:650-757-3009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY449563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0596835OtherNCPDP PROVIDER IDENTIFICATION NUMBER
0596835OtherNCPDP PROVIDER IDENTIFICATION NUMBER
0700980163Medicare NSC