Healthcare Provider Details

I. General information

NPI: 1528306081
Provider Name (Legal Business Name): RXMEDLAB PHARMACY , LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2013
Last Update Date: 01/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 NE BEACON DR SUITE # 109
GRANTS PASS OR
97526-4260
US

IV. Provider business mailing address

162 NE BEACON DR SUITE # 109
GRANTS PASS OR
97526-4260
US

V. Phone/Fax

Practice location:
  • Phone: 541-474-3784
  • Fax:
Mailing address:
  • Phone: 541-474-3784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number2763
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number2763
License Number StateOR

VIII. Authorized Official

Name: MR. DENNIS RAY CLARK
Title or Position: PHARMACIST / OWNER
Credential: R.PH.
Phone: 541-474-3784