Provider Demographics
NPI:1679561005
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:MINER
Authorized Official - Last Name:STOCKING
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
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:99206-3634
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:99206-3634
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:2005-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA262010403850333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6171706Medicaid
WA6171706Medicaid