MEDICARE: BAINBRIDGE ISLAND COMMUNITY PHARMACY LLC

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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy

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	2168189	OTHER		PK

General Provider Information

NPI Number	:	1073053302
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAINBRIDGE ISLAND COMMUNITY PHARMACY LLC

Provider Business Mailing Address
First Line	:	124 WINSLOW WAY W
Second Line	:
City	:	BAINBRIDGE ISLAND
State	:	WA
Zip	:	98110-2512
Country	:	US
Telephone Number	:	206-780-7809
Fax Number	:	206-842-7801

Provider Business Practice Location Address
First Line	:	124 WINSLOW WAY W
Second Line	:
City	:	BAINBRIDGE ISLAND
State	:	WA
Zip	:	98110-2512
Country	:	US
Telephone Number	:	206-780-7809
Fax Number	:	206-842-7801

Authorized Official
Title or Position	:	MEMBER
Name	:	MARK JOWETT TAN
Credential	:
Telephone Number	:	206-780-7809

Provider Enumeration Date	:	03/06/2017
Last Update Date	:	12/06/2023

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