Healthcare Provider Details

I. General information

NPI: 1336797620
Provider Name (Legal Business Name): MADISON PARK PHARMACY AND WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2019
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24255 VAN RY BLVD STE A2
MOUNTLAKE TERRACE WA
98043
US

IV. Provider business mailing address

PO BOX B
ILWACO WA
98624-0167
US

V. Phone/Fax

Practice location:
  • Phone: 425-672-5800
  • Fax: 425-672-5811
Mailing address:
  • Phone: 425-672-5800
  • Fax: 425-672-5811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number StateNULL

VIII. Authorized Official

Name: JEFFREY SHANE HARRELL
Title or Position: PRESIDENT
Credential:
Phone: 360-859-8659