Provider Demographics
NPI:1699818757
Name:FOUNTAIN DRUG AND VARIETY INC
Entity Type:Organization
Organization Name:FOUNTAIN DRUG AND VARIETY INC
Other - Org Name:FOUNTAIN DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST AND TECHNICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:COUDRIET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-733-6200
Mailing Address - Street 1:2416 MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-2405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2416 MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-2405
Practice Address - Country:US
Practice Address - Phone:360-733-6200
Practice Address - Fax:360-671-4644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WACF000022193336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4902296OtherOTHER ID NUMBER-COMMERCIAL NUMBER
4902296OtherOTHER ID NUMBER
WA6003784Medicaid