Healthcare Provider Details

I. General information

NPI: 1124423793
Provider Name (Legal Business Name): CASCADE COMPOUNDING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2014
Last Update Date: 10/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19550 AMBER MEADOW DR SUITE 170
BEND OR
97702-3525
US

IV. Provider business mailing address

19550 AMBER MEADOW DR STE B
BEND OR
97702-3525
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberRP-0002988-CS
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name: ERICK R SCHEIDERMAN
Title or Position: SOLE MEMBER
Credential: OWNER
Phone: 541-389-3671