Provider Demographics
NPI:1568575892
Name:ROSAUERS SUPERMARKETS, INC.
Entity Type:Organization
Organization Name:ROSAUERS SUPERMARKETS, INC.
Other - Org Name:ROSAUERS PHARMACY #3
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:MR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:STOCKING
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:509-326-8900
Mailing Address - Street 1:10618 E SPRAGUE AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-3632
Mailing Address - Country:US
Mailing Address - Phone:509-924-5560
Mailing Address - Fax:509-927-8518
Practice Address - Street 1:10618 E SPRAGUE AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-3632
Practice Address - Country:US
Practice Address - Phone:509-924-5560
Practice Address - Fax:509-927-8518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2620104038503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6171706Medicaid
WI0636370002Medicare NSC