Healthcare Provider Details

I. General information

NPI: 1972543734
Provider Name (Legal Business Name): YANTIS ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 03/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29670 ELLENSBURG AVE
GOLD BEACH OR
97444-8701
US

IV. Provider business mailing address

29670 ELLENSBURG AVE
GOLD BEACH OR
97444-8701
US

V. Phone/Fax

Practice location:
  • Phone: 541-247-4544
  • Fax: 541-247-2604
Mailing address:
  • Phone: 541-247-4544
  • Fax: 541-247-2604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberRP0000218
License Number StateOR

VIII. Authorized Official

Name: TIMOTHY YANTIS
Title or Position: OWNER
Credential:
Phone: 541-247-4544