Provider Demographics
NPI:1073895496
Name:COSTCO WHOLESALE CORPORATION
Entity Type:Organization
Organization Name:COSTCO WHOLESALE CORPORATION
Other - Org Name:COSTCO PHARMACY # 1102
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:
Mailing Address - Fax:
Practice Address - Street 1:825 CABELA DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-8202
Practice Address - Country:US
Practice Address - Phone:706-739-1701
Practice Address - Fax:706-739-1702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-12
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0097873336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1161734OtherNCPDP PROVIDER IDENTIFICATION NUMBER
2131887OtherPK
1161734OtherNCPDP PROVIDER IDENTIFICATION NUMBER
PHC067Medicare PIN