Provider Demographics
NPI:1902027253
Name:COUNTRY DOCTOR COMMUNITY CLINIC
Entity Type:Organization
Organization Name:COUNTRY DOCTOR COMMUNITY CLINIC
Other - Org Name:CAROLYN DOWNS FAMILY MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SAUCEDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-709-7112
Mailing Address - Street 1:2101 E YESLER WAY
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-5959
Mailing Address - Country:US
Mailing Address - Phone:206-299-1970
Mailing Address - Fax:206-299-1920
Practice Address - Street 1:2101 E YESLER WAY
Practice Address - Street 2:SUITE 150
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-5959
Practice Address - Country:US
Practice Address - Phone:206-299-1900
Practice Address - Fax:206-299-1920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPHAR.CF.00004988OtherLICENSE NUMBER