Provider Demographics
NPI:1881718674
Name:UNION AVENUE COMPOUNDING PHARMACY
Entity type:Organization
Organization Name:UNION AVENUE COMPOUNDING PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BURKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-752-1705
Mailing Address - Street 1:2302 S UNION AVE
Mailing Address - Street 2:C25
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1300
Mailing Address - Country:US
Mailing Address - Phone:253-752-1705
Mailing Address - Fax:253-761-9315
Practice Address - Street 1:2302 S UNION AVE
Practice Address - Street 2:C25
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1300
Practice Address - Country:US
Practice Address - Phone:253-752-1705
Practice Address - Fax:253-761-9315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACF00057609332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9014036OtherDME
WA9014036OtherDME