MEDICARE: OREGON HEALTHCARE PHARMACY SERVICES INC

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	3336L0003X	Long Term Care Pharmacy
2	333600000X	Pharmacy	054.016954	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2020977	OTHER		PK

General Provider Information

NPI Number	:	1699838227
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OREGON HEALTHCARE PHARMACY SERVICES INC

Provider Business Mailing Address
First Line	:	1100 PINES RD
Second Line	:
City	:	OREGON
State	:	IL
Zip	:	61061-9653
Country	:	US
Telephone Number	:	815-732-1422
Fax Number	:	815-732-1532

Provider Business Practice Location Address
First Line	:	1100 PINES RD
Second Line	:
City	:	OREGON
State	:	IL
Zip	:	61061-9653
Country	:	US
Telephone Number	:	815-732-1422
Fax Number	:	815-732-1532

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MARC MONGAN
Credential	:	RPH
Telephone Number	:	815-732-1422

Provider Enumeration Date	:	12/18/2006
Last Update Date	:	12/06/2016

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