Provider Demographics
NPI:1326183724
Name:MEDICINE MAN, INC.
Entity Type:Organization
Organization Name:MEDICINE MAN, INC.
Other - Org Name:MEDICINE MAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-789-0800
Mailing Address - Street 1:323 N 85TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-3605
Mailing Address - Country:US
Mailing Address - Phone:877-789-0800
Mailing Address - Fax:206-781-8006
Practice Address - Street 1:323 N 85TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-3605
Practice Address - Country:US
Practice Address - Phone:877-789-0800
Practice Address - Fax:206-781-8006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACF000041963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6164701Medicaid
WA6164701Medicaid