MEDICARE: COSTCO WHOLESALE CORPORATION

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	332H00000X	Eyewear Supplier	D7368	CA

General Provider Information

NPI Number	:	1235529447
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COSTCO WHOLESALE CORPORATION

Provider Business Mailing Address
First Line	:	PO BOX 35005
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98124-3405
Country	:	US
Telephone Number	:	425-313-8100
Fax Number	:	425-313-6922

Provider Business Practice Location Address
First Line	:	340 LAKEWOOD CENTER MALL
Second Line	:
City	:	LAKEWOOD
State	:	CA
Zip	:	90712-2409
Country	:	US
Telephone Number	:	562-295-1517
Fax Number	:	562-295-1510

Authorized Official
Title or Position	:	AVP OPTICAL
Name	:	ART SALAS
Credential	:
Telephone Number	:	562-295-1517

Provider Enumeration Date	:	01/26/2015
Last Update Date	:	06/12/2020

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