Provider Demographics
NPI:1932240892
Name:JACK J CORDOVA
Entity Type:Organization
Organization Name:JACK J CORDOVA
Other - Org Name:GEORGETOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:CORDOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-763-0288
Mailing Address - Street 1:6111 13TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98108-2705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6111 13TH AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98108-2705
Practice Address - Country:US
Practice Address - Phone:206-763-0288
Practice Address - Fax:206-768-1296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WACF000003003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4906775OtherNCPDP PROVIDER IDENTIFICATION NUMBER
WA6030407Medicaid
0585600001Medicare NSC