MEDICARE: ROCHESTER DRUG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy		WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033116983
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROCHESTER DRUG

Provider Business Mailing Address
First Line	:	7505 183RD AVE SW
Second Line	:	UNIT C
City	:	ROCHESTER
State	:	WA
Zip	:	98579
Country	:	US
Telephone Number	:	360-273-5522
Fax Number	:	360-273-8067

Provider Business Practice Location Address
First Line	:	7505 183RD AVE SW UNIT C
Second Line	:
City	:	ROCHESTER
State	:	WA
Zip	:	98579-9212
Country	:	US
Telephone Number	:	360-273-5522
Fax Number	:	360-273-8067

Authorized Official
Title or Position	:	OWNER PHARMACIST
Name	:	MR. CRAIG TAVIS
Credential	:	RPH
Telephone Number	:	360-273-5522

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	04/20/2008

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Directions to “ROCHESTER DRUG ” Practice Location

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