Healthcare Provider Details

I. General information

NPI: 1528213790
Provider Name (Legal Business Name): CASCADE APOTHECARY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2008
Last Update Date: 03/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19550 AMBER MEADOW DR STE 170
BEND OR
97702-3527
US

IV. Provider business mailing address

19550 SW AMBER MEADOW DR STE. 170
BEND OR
97702
US

V. Phone/Fax

Practice location:
  • Phone: 541-389-3671
  • Fax: 541-728-0988
Mailing address:
  • Phone: 541-389-3671
  • Fax: 541-385-6260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberRP0002541CS
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2146844
Identifier TypeOTHER
Identifier State
Identifier IssuerPK
# 2
Identifier500675098
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: ANGELA VALERGA
Title or Position: PRESIDENT
Credential:
Phone: 541-389-3671