Provider Demographics
NPI:1154799922
Name:COSTCO 1042
Entity type:Organization
Organization Name:COSTCO 1042
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAKSHMI
Authorized Official - Middle Name:
Authorized Official - Last Name:GANGIREDLA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:650-568-4049
Mailing Address - Street 1:2300 MIDDLEFIELD RD
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-2854
Mailing Address - Country:US
Mailing Address - Phone:650-568-4049
Mailing Address - Fax:
Practice Address - Street 1:2300 MIDDLEFIELD RD
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-2854
Practice Address - Country:US
Practice Address - Phone:650-568-4049
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56490333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy