Provider Demographics
NPI:1972607927
Name:BALLARD PLAZA PHARMACY I INC
Entity type:Organization
Organization Name:BALLARD PLAZA PHARMACY I INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-782-7200
Mailing Address - Street 1:1801 NW MARKET ST
Mailing Address - Street 2:104
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-3987
Mailing Address - Country:US
Mailing Address - Phone:206-782-7200
Mailing Address - Fax:206-782-3571
Practice Address - Street 1:1801 NW MARKET ST
Practice Address - Street 2:104
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-3987
Practice Address - Country:US
Practice Address - Phone:206-782-7200
Practice Address - Fax:206-782-3571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WACF000582683336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6029292Medicaid
4911308OtherNCPDP PROVIDER IDENTIFICATION NUMBER
4911308OtherNCPDP PROVIDER IDENTIFICATION NUMBER