Provider Demographics
NPI:1699764399
Name:GRANITE DRUGS, LLC
Entity type:Organization
Organization Name:GRANITE DRUGS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KARI
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDERHOUWEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-915-7888
Mailing Address - Street 1:207 E STANLEY ST STE A
Mailing Address - Street 2:
Mailing Address - City:GRANITE FALLS
Mailing Address - State:WA
Mailing Address - Zip Code:98252-8480
Mailing Address - Country:US
Mailing Address - Phone:360-691-7778
Mailing Address - Fax:360-691-4458
Practice Address - Street 1:207 E STANLEY ST # A
Practice Address - Street 2:
Practice Address - City:GRANITE FALLS
Practice Address - State:WA
Practice Address - Zip Code:98252-8480
Practice Address - Country:US
Practice Address - Phone:360-691-7778
Practice Address - Fax:360-691-4458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-17
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACF00057675333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4915712OtherNABP
WA6003305Medicaid
WA6003305Medicaid