Provider Demographics
NPI:1841201340
Name:WSM BELVEDERE INC
Entity Type:Organization
Organization Name:WSM BELVEDERE INC
Other - Org Name:MAPLE LEAF PHARMACY UNITED DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCNARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-729-7514
Mailing Address - Street 1:8830 ROOSEVELT WAY NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-3042
Mailing Address - Country:US
Mailing Address - Phone:206-729-7514
Mailing Address - Fax:206-729-7513
Practice Address - Street 1:8830 ROOSEVELT WAY NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-3042
Practice Address - Country:US
Practice Address - Phone:206-729-7514
Practice Address - Fax:206-729-7513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WA2620103033743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6005441Medicaid
4918984OtherNCPDP PROVIDER IDENTIFICATION NUMBER
WA6005441Medicaid