Provider Demographics
NPI:1376277236
Name:HAWKS PRAIRIE PHARMACY
Entity Type:Organization
Organization Name:HAWKS PRAIRIE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUNIL
Authorized Official - Middle Name:B
Authorized Official - Last Name:THIMMEGOWDA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:360-438-3072
Mailing Address - Street 1:2539 MARVIN RD NE STE E
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-3175
Mailing Address - Country:US
Mailing Address - Phone:360-438-3072
Mailing Address - Fax:360-438-3532
Practice Address - Street 1:2539 MARVIN RD NE STE E
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-3175
Practice Address - Country:US
Practice Address - Phone:360-438-3072
Practice Address - Fax:360-438-3532
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAWKS PRAIRIE PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-07-14
Last Update Date:2022-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1508292707OtherNPI
WA2031538Medicaid