Healthcare Provider Details

I. General information

NPI: 1689873242
Provider Name (Legal Business Name): NEW SEASONS MARKET - HAPPY VALLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15861 SE HAPPY VALLEY TOWN CENTER DR.
HAPPY VALLEY OR
97086
US

IV. Provider business mailing address

15861 SE HAPPY VALLEY TOWN CENTER DR.
HAPPY VALLEY OR
97086
US

V. Phone/Fax

Practice location:
  • Phone: 503-558-9215
  • Fax: 503-658-8470
Mailing address:
  • Phone: 503-558-9215
  • Fax: 503-658-8470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberRP-0002413-CS
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberRP-0002413-CS
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License NumberRP-0002413-CS
License Number StateOR

VIII. Authorized Official

Name: MR. ERIC L FOXMAN
Title or Position: PHARMACY MANAGER
Credential: R.PH.
Phone: 503-558-9215