Provider Demographics
NPI:1528199619
Name:PORT TOWNSEND PHARMACY INC.
Entity Type:Organization
Organization Name:PORT TOWNSEND PHARMACY INC.
Other - Org Name:DON'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:
Authorized Official - Last Name:PERILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-473-1155
Mailing Address - Street 1:1151 WATER ST
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-6707
Mailing Address - Country:US
Mailing Address - Phone:360-385-0969
Mailing Address - Fax:360-385-2843
Practice Address - Street 1:1151 WATER ST
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-6707
Practice Address - Country:US
Practice Address - Phone:360-385-0969
Practice Address - Fax:360-385-2843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
WACF000020643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6134605Medicaid
WA0010181Medicaid