Provider Demographics
NPI:1497975619
Name:MIKES EASTSIDE DRUGS
Entity Type:Organization
Organization Name:MIKES EASTSIDE DRUGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAEFF
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARMACY
Authorized Official - Phone:360-694-0800
Mailing Address - Street 1:8506 E MILL PLAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-2011
Mailing Address - Country:US
Mailing Address - Phone:360-694-0800
Mailing Address - Fax:
Practice Address - Street 1:8506 E MILL PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-2011
Practice Address - Country:US
Practice Address - Phone:360-694-0800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACF00001931332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6082606Medicaid
WA0265930001Medicare ID - Type UnspecifiedMEDICARE