Provider Demographics
NPI:1750413829
Name:MARKET STREET PHARMACY
Entity type:Organization
Organization Name:MARKET STREET PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:STIMAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-783-2960
Mailing Address - Street 1:1723 NW MARKET ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-5225
Mailing Address - Country:US
Mailing Address - Phone:206-783-2960
Mailing Address - Fax:206-784-7522
Practice Address - Street 1:1723 NW MARKET ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-5225
Practice Address - Country:US
Practice Address - Phone:206-783-2960
Practice Address - Fax:206-784-7522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA00013336183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6019566Medicaid
WA6019566Medicaid