Healthcare Provider Details

I. General information

NPI: 1821571662
Provider Name (Legal Business Name): PRIME PHARMACY CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2018
Last Update Date: 06/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 RAINIER AVE S
RENTON WA
98057-2047
US

IV. Provider business mailing address

64 RAINIER AVE S STE H
RENTON WA
98057-2047
US

V. Phone/Fax

Practice location:
  • Phone: 206-931-3557
  • Fax: 206-829-4906
Mailing address:
  • Phone: 206-829-4908
  • Fax: 206-829-4906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPH40213
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberPH40213
License Number StateWA

VIII. Authorized Official

Name: DANNY DANG
Title or Position: PRESIDENT
Credential: PHARM D
Phone: 206-829-4908