Provider Demographics
NPI:1467867648
Name:COSTCO WHOLESALE CORPORATION
Entity Type:Organization
Organization Name:COSTCO WHOLESALE CORPORATION
Other - Org Name:COSTCO PHARMACY #1178
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AVP -PHARMACY SERVICES
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:
Mailing Address - Fax:
Practice Address - Street 1:4705 WEITZEL ST.
Practice Address - Street 2:
Practice Address - City:TIMNATH
Practice Address - State:CO
Practice Address - Zip Code:80547
Practice Address - Country:US
Practice Address - Phone:970-416-6125
Practice Address - Fax:970-416-6116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-25
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPDO.16800000723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146709OtherPK