Healthcare Provider Details

I. General information

NPI: 1770842536
Provider Name (Legal Business Name): COSTCO PHARMACY 218
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2012
Last Update Date: 05/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21398 PRICE CASCADES PLAZA
STERLING VA
20164
US

IV. Provider business mailing address

21398 PRICE CASCADES PLAZA
STERLING VA
20164
US

V. Phone/Fax

Practice location:
  • Phone: 703-406-7048
  • Fax: 703-406-7045
Mailing address:
  • Phone: 703-406-7048
  • Fax: 703-406-7045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number0202010260
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number0202010260
License Number StateVA

VIII. Authorized Official

Name: MS. ELSA LAM
Title or Position: STAFF PHARMACIST
Credential: RPH
Phone: 703-406-7046