Provider Demographics
NPI:1164505202
Name:COSTCO WHOLESALE CORPORATION
Entity Type:Organization
Organization Name:COSTCO WHOLESALE CORPORATION
Other - Org Name:COSTCO PHARMACY #638
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 1:79795 HIGHWAY 111
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-4756
Practice Address - Country:US
Practice Address - Phone:760-342-0656
Practice Address - Fax:760-775-0367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY483113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5624259OtherNCPDP PROVIDER IDENTIFICATION NUMBER
PHC067Medicare PIN
5624259OtherNCPDP PROVIDER IDENTIFICATION NUMBER