Healthcare Provider Details

I. General information

NPI: 1457411779
Provider Name (Legal Business Name): GRANTS PASS PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 08/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 SW 6TH ST
GRANTS PASS OR
97526-2810
US

IV. Provider business mailing address

414 SW 6TH ST
GRANTS PASS OR
97526-2810
US

V. Phone/Fax

Practice location:
  • Phone: 541-476-4262
  • Fax: 541-474-1443
Mailing address:
  • Phone: 541-476-4262
  • Fax: 541-474-1443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number00225
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number00225
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier076356
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: MS. MICHELE M BELCHER
Title or Position: VP OF OPERATIONS
Credential: R.PH
Phone: 541-476-4262