Provider Demographics
NPI:1508292707
Name:HAWKS PRAIRIE PHARMACY
Entity Type:Organization
Organization Name:HAWKS PRAIRIE PHARMACY
Other - Org Name:HAWKS PRAIRIE HEALTH MART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:SUNIL
Authorized Official - Middle Name:B
Authorized Official - Last Name:THIMMEGOWDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-438-3072
Mailing Address - Street 1:2539 MARVIN RD NE
Mailing Address - Street 2:STE E
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-3177
Mailing Address - Country:US
Mailing Address - Phone:360-438-3072
Mailing Address - Fax:360-438-3532
Practice Address - Street 1:2539 MARVIN RD NE
Practice Address - Street 2:STE E
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-3177
Practice Address - Country:US
Practice Address - Phone:360-438-3072
Practice Address - Fax:360-438-3532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-19
Last Update Date:2023-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X, 332B00000X, 3336M0003X
WAPHAR.CF.60409528333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8924654OtherMEDICARE MASS IMMUNIZATION
WA7054150001Medicare NSC