Healthcare Provider Details

I. General information

NPI: 1477711802
Provider Name (Legal Business Name): CONFEDERATED TRIBES OF THE GRAND RONDE COMMUNITY OF OREGON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2008
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9605 GRAND RONDE RD
GRAND RONDE OR
97347-9712
US

IV. Provider business mailing address

9605 GRAND RONDE RD
GRAND RONDE OR
97347-9712
US

V. Phone/Fax

Practice location:
  • Phone: 503-879-2342
  • Fax: 503-879-2030
Mailing address:
  • Phone: 503-879-2060
  • Fax: 503-879-2071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: LINCOLN WRIGHT
Title or Position: PHARMACY DIRECTOR
Credential: PHARMD
Phone: 503-879-2299