Provider Demographics
NPI:1639390982
Name:COUNTRY DOCTOR COMMUNITY CLINIC
Entity Type:Organization
Organization Name:COUNTRY DOCTOR COMMUNITY CLINIC
Other - Org Name:COUNTRY DOCTOR COMMUNITY CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SAUCEDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-709-7112
Mailing Address - Street 1:510 19TH AVE E
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98112-4095
Mailing Address - Country:US
Mailing Address - Phone:206-709-7116
Mailing Address - Fax:206-299-1920
Practice Address - Street 1:510 19TH AVE E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-4095
Practice Address - Country:US
Practice Address - Phone:206-709-7116
Practice Address - Fax:206-299-1608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACF000047293336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPHAR.CF.61403411OtherLICENSE NUMBER