Provider Demographics
NPI:1114237633
Name:POULSBO COMPOUNDING PHARMACY LLC
Entity Type:Organization
Organization Name:POULSBO COMPOUNDING PHARMACY LLC
Other - Org Name:CASCADE SPECIALTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:KNOTT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:360-779-2737
Mailing Address - Street 1:PO BOX 2850
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-2850
Mailing Address - Country:US
Mailing Address - Phone:360-779-2737
Mailing Address - Fax:360-779-4905
Practice Address - Street 1:325 NE HOSTMARK ST
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-6668
Practice Address - Country:US
Practice Address - Phone:360-779-2737
Practice Address - Fax:360-779-4905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-18
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602643953336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2134570OtherPK