Provider Demographics
NPI:1164826772
Name:COSTCO
Entity Type:Organization
Organization Name:COSTCO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:773-988-2479
Mailing Address - Street 1:1224 INVERRARY LN
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-3612
Mailing Address - Country:US
Mailing Address - Phone:773-988-2479
Mailing Address - Fax:
Practice Address - Street 1:25901 N RIVERWOODS RD
Practice Address - Street 2:
Practice Address - City:METTAWA
Practice Address - State:IL
Practice Address - Zip Code:60045-3403
Practice Address - Country:US
Practice Address - Phone:847-235-1302
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-11
Last Update Date:2014-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051295396261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service