Healthcare Provider Details

I. General information

NPI: 1295231736
Provider Name (Legal Business Name): EMERALD TITAN HOLDINGS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 04/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7311 40TH ST W
UNIVERSITY PLACE WA
98466-4316
US

IV. Provider business mailing address

7311 40TH ST W
UNIVERSITY PLACE WA
98466-4316
US

V. Phone/Fax

Practice location:
  • Phone: 253-448-2460
  • Fax: 253-507-8621
Mailing address:
  • Phone: 253-448-2460
  • Fax: 253-507-8621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHAR.CF.6079962
License Number StateWA

VII. Legacy identifiers

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

# 1
Identifier2176874
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: CARLO CADIZ
Title or Position: PHARMACIST
Credential:
Phone: 732-322-2931