Provider Demographics
NPI:1366827933
Name:COSTCO
Entity Type:Organization
Organization Name:COSTCO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:301-644-1482
Mailing Address - Street 1:10 MONOCACY BLVD
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21704-7256
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 MONOCACY BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21704-7256
Practice Address - Country:US
Practice Address - Phone:301-644-1482
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-24
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1835P0018X
MD22474261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Multi-Specialty
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or LocalGroup - Multi-Specialty