Provider Demographics
NPI:1821571662
Name:PRIME PHARMACY CORP
Entity Type:Organization
Organization Name:PRIME PHARMACY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:
Authorized Official - Last Name:DANG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:206-829-4908
Mailing Address - Street 1:64 RAINIER AVE S STE H
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-2047
Mailing Address - Country:US
Mailing Address - Phone:206-829-4908
Mailing Address - Fax:206-829-4906
Practice Address - Street 1:64 RAINIER AVE S
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-2047
Practice Address - Country:US
Practice Address - Phone:206-931-3557
Practice Address - Fax:206-829-4906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-07
Last Update Date:2019-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH402133336C0004X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1821571662Medicaid