Provider Demographics
NPI:1558714477
Name:COSTCO
Entity Type:Organization
Organization Name:COSTCO
Other - Org Name:PHARNACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:WEISLER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:954-551-4692
Mailing Address - Street 1:11064 BRANDYWINE LAKE WAY
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33473-4888
Mailing Address - Country:US
Mailing Address - Phone:954-551-4692
Mailing Address - Fax:954-972-0368
Practice Address - Street 1:1800 W SAMPLE RD
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064-1324
Practice Address - Country:US
Practice Address - Phone:954-972-0313
Practice Address - Fax:954-972-9738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-15
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS152751835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========8Medicaid