Healthcare Provider Details

I. General information

NPI: 1053182923
Provider Name (Legal Business Name): 1918 WINTER STREET OPERATING CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2024
Last Update Date: 07/24/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 MONROE AVE
ENUMCLAW WA
98022-2993
US

IV. Provider business mailing address

7 CORPORATE DR
KEENE NH
03431-5042
US

V. Phone/Fax

Practice location:
  • Phone: 360-825-9360
  • Fax: 360-825-9424
Mailing address:
  • Phone: 603-354-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KEVIN MCNAMARA
Title or Position: AUTHORIZED PERSON
Credential:
Phone: 603-354-4619