=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699887505
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MILL CREEK PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 05/06/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1025 153RD ST SE STE 104
-----------------------------------------------------
City | MILL CREEK
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98012-4051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-481-7575
-----------------------------------------------------
Fax | 425-338-0167
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1025 153RD ST SE STE 104
-----------------------------------------------------
City | MILL CREEK
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98012-4051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-481-7575
-----------------------------------------------------
Fax | 425-338-0167
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MICHAEL SOMERS
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 425-481-7575
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0002X
-----------------------------------------------------
Taxonomy Name | Clinic Pharmacy
-----------------------------------------------------
License Number | PHARCF00003562
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------