Provider Demographics
NPI:1215930300
Name:KIRK'S DRUG, INC
Entity type:Organization
Organization Name:KIRK'S DRUG, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:WALETICH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:360-694-7377
Mailing Address - Street 1:6149 MARTIN WAY E
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-5547
Mailing Address - Country:US
Mailing Address - Phone:360-493-8614
Mailing Address - Fax:360-493-8612
Practice Address - Street 1:6906 MARTIN WAY
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98516-5567
Practice Address - Country:US
Practice Address - Phone:360-456-5475
Practice Address - Fax:360-491-2161
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KIRK'S DRUG, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-05-23
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA332BX2000X
332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1005114Medicaid
WA9011800Medicaid
WA9011800Medicaid
WA1005114Medicaid