Provider Demographics
NPI:1396839643
Name:COSTCO WHOLESALE CORPORATION
Entity Type:Organization
Organization Name:COSTCO WHOLESALE CORPORATION
Other - Org Name:COSTCO PHARMACY # 733
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AVP PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTROMONICA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-313-2892
Mailing Address - Street 1:PO BOX 34300
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1300
Mailing Address - Country:US
Mailing Address - Phone:425-313-6670
Mailing Address - Fax:425-313-6595
Practice Address - Street 1:198 N 1200 E
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-2294
Practice Address - Country:US
Practice Address - Phone:801-653-2709
Practice Address - Fax:801-653-2706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2014-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT626745117033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4610576OtherNCPDP PROVIDER IDENTIFICATION NUMBER
PHC067Medicare PIN
4610576OtherNCPDP PROVIDER IDENTIFICATION NUMBER