Provider Demographics
NPI:1386690204
Name:HAGGEN OPCO NORTH LLC
Entity Type:Organization
Organization Name:HAGGEN OPCO NORTH LLC
Other - Org Name:HAGGEN PHARMACY #105
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE SENIOR VICE PRESIDENT, PH
Authorized Official - Prefix:
Authorized Official - First Name:GAETANO
Authorized Official - Middle Name:
Authorized Official - Last Name:DIPASQUA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-650-8204
Mailing Address - Street 1:2211 RIMLAND DR
Mailing Address - Street 2:STE 300
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-5664
Mailing Address - Country:US
Mailing Address - Phone:360-733-8720
Mailing Address - Fax:360-752-6437
Practice Address - Street 1:450 N WILBUR AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2254
Practice Address - Country:US
Practice Address - Phone:509-529-3706
Practice Address - Fax:509-529-3788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA605344053336C0003X
333600000X
WAPHAR.CF.603425313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2150624OtherPK
2107474OtherPK
0483391378Medicare NSC