Provider Demographics
NPI:1699887505
Name:MILL CREEK PHARMACY INC
Entity type:Organization
Organization Name:MILL CREEK PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SOMERS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:425-481-7575
Mailing Address - Street 1:1025 153RD ST SE STE 104
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-4051
Mailing Address - Country:US
Mailing Address - Phone:425-481-7575
Mailing Address - Fax:425-338-0167
Practice Address - Street 1:1025 153RD ST SE STE 104
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-4051
Practice Address - Country:US
Practice Address - Phone:425-481-7575
Practice Address - Fax:425-338-0167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WAPHARCF000035623336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4916269OtherNCPDP PROVIDER IDENTIFICATION NUMBER
WA6145601Medicaid