Provider Demographics
NPI:1366827834
Name:FRED MEYER PHARMACY
Entity Type:Organization
Organization Name:FRED MEYER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:IVO
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRTCHEV
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:702-460-4364
Mailing Address - Street 1:1530 15TH AVE UNIT 511
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-3981
Mailing Address - Country:US
Mailing Address - Phone:702-460-4364
Mailing Address - Fax:
Practice Address - Street 1:301 E WALLACE KNEELAND BLVD
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-2985
Practice Address - Country:US
Practice Address - Phone:702-460-4364
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA605466343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy