Provider Demographics
NPI:1184706772
Name:THE BARTELL DRUG CO
Entity type:Organization
Organization Name:THE BARTELL DRUG CO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR VP OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:KOO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-763-2626
Mailing Address - Street 1:4025 DELRIDGE WAY SW
Mailing Address - Street 2:STE 400
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98106-1249
Mailing Address - Country:US
Mailing Address - Phone:206-767-1316
Mailing Address - Fax:206-767-1397
Practice Address - Street 1:1115 13TH ST
Practice Address - Street 2:
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98290-2012
Practice Address - Country:US
Practice Address - Phone:360-568-0548
Practice Address - Fax:360-568-5151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WACF000054273336C0003X
WACF.00005427333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2108173OtherPK
WA0333520047Medicaid
WA6015937Medicaid
WA6015937Medicaid
WAP00070933OtherMEDICARE B RAILROAD
WA6015937OtherMEDICAID DME