Provider Demographics
NPI:1093799843
Name:PHARMACY CORPORATION OF AMERICA
Entity Type:Organization
Organization Name:PHARMACY CORPORATION OF AMERICA
Other - Org Name:PROPAC PAYLESS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:LARIVIERE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-627-7404
Mailing Address - Street 1:PO BOX 409244
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-9244
Mailing Address - Country:US
Mailing Address - Phone:813-378-6274
Mailing Address - Fax:813-318-6346
Practice Address - Street 1:111 SE EVERETT MALL WAY
Practice Address - Street 2:STE A100
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-3208
Practice Address - Country:US
Practice Address - Phone:503-626-9436
Practice Address - Fax:800-982-2730
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHARMERICA HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-05
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WAPHAR.CF604084363336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2108264OtherPK
WA6024269Medicaid
WA6024269Medicaid