Provider Demographics
NPI:1427168053
Name:COSTCO WHOLESALE CORPORATION
Entity type:Organization
Organization Name:COSTCO WHOLESALE CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR INSURANCE PLANS
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:TAKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-313-6670
Mailing Address - Street 1:3700 PRICE CLUB BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-3371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3700 PRICE CLUB BLVD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3371
Practice Address - Country:US
Practice Address - Phone:804-674-5861
Practice Address - Fax:804-674-6502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2008-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201003356333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8502919Medicaid
4830089OtherOTHER ID NUMBER-COMMERCIAL NUMBER
VA8502919Medicaid