Provider Demographics
NPI:1649271214
Name:CITY CENTER DRUG INC
Entity type:Organization
Organization Name:CITY CENTER DRUG INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:O DONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-532-5182
Mailing Address - Street 1:108 E WISHKAH ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-6508
Mailing Address - Country:US
Mailing Address - Phone:360-532-5182
Mailing Address - Fax:360-532-5887
Practice Address - Street 1:108 E WISHKAH ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-6508
Practice Address - Country:US
Practice Address - Phone:360-532-5182
Practice Address - Fax:360-532-5887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-04
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WACF000592253336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2106523OtherPK
WA6027882Medicaid
2106523OtherPK