Healthcare Provider Details

I. General information

NPI: 1508292707
Provider Name (Legal Business Name): HAWKS PRAIRIE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2013
Last Update Date: 11/11/2023
Certification Date: 11/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2539 MARVIN RD NE STE E
LACEY WA
98516-3177
US

IV. Provider business mailing address

2539 MARVIN RD NE STE E
LACEY WA
98516-3177
US

V. Phone/Fax

Practice location:
  • Phone: 360-438-3072
  • Fax: 360-438-3532
Mailing address:
  • Phone: 360-438-3072
  • Fax: 360-438-3532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHAR.CF.60409528
License Number StateWA

VIII. Authorized Official

Name: MR. SUNIL B THIMMEGOWDA
Title or Position: OWNER/PHARMACIST
Credential:
Phone: 360-438-3072