Provider Demographics
NPI:1679014153
Name:COSTCO WHOLESALE CORPORATION
Entity Type:Organization
Organization Name:COSTCO WHOLESALE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-328-7610
Mailing Address - Street 1:170 COOLEY MESA ROAD
Mailing Address - Street 2:
Mailing Address - City:GYPSUM
Mailing Address - State:CO
Mailing Address - Zip Code:81631
Mailing Address - Country:US
Mailing Address - Phone:970-376-7841
Mailing Address - Fax:970-328-7607
Practice Address - Street 1:170 COOLEY MESA ROAD
Practice Address - Street 2:
Practice Address - City:GYPSUM
Practice Address - State:CO
Practice Address - Zip Code:81631
Practice Address - Country:US
Practice Address - Phone:970-376-7841
Practice Address - Fax:970-328-7607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-16
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO21340251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health