Basic Information
| Provider Information | |||||||||
| NPI: | 1184976508 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COSTCO WHOLESALE CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 999 LAKE DR | ||||||||
| Address2: | |||||||||
| City: | ISSAQUAH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980278990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253136289 | ||||||||
| FaxNumber: | 4253136595 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 W WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | EAST PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094272931 | ||||||||
| FaxNumber: | 3094272932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2012 | ||||||||
| LastUpdateDate: | 07/23/2018 | ||||||||
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| AuthorizedOfficialLastName: | CURTIS | ||||||||
| AuthorizedOfficialFirstName: | VICTOR | ||||||||
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| AuthorizedOfficialTitleorPosition: | SVP PHARMACY | ||||||||
| AuthorizedOfficialTelephone: | 4253137206 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | 054018048 | IL | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2137371 | 01 | PK | OTHER | 1487417 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |