Provider Demographics
NPI:1104821701
Name:RXTRACARE PHARMACY INC
Entity type:Organization
Organization Name:RXTRACARE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-632-7613
Mailing Address - Street 1:29 148TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007-5113
Mailing Address - Country:US
Mailing Address - Phone:425-747-3800
Mailing Address - Fax:425-641-7203
Practice Address - Street 1:29 148TH AVE SE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-5113
Practice Address - Country:US
Practice Address - Phone:425-747-3800
Practice Address - Fax:425-641-7203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA332B00000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9035346Medicaid
WA6146005Medicaid
WA9044983Medicaid
WA4900595OtherNABP
WA6146005Medicaid