Healthcare Provider Details

I. General information

NPI: 1669569869
Provider Name (Legal Business Name): J MAC DRUG INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2006
Last Update Date: 02/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15685 SW 116TH AVE
KING CITY OR
97224-2651
US

IV. Provider business mailing address

15685 SW 116TH AVE
KING CITY OR
97224-2651
US

V. Phone/Fax

Practice location:
  • Phone: 503-639-1171
  • Fax: 503-620-2167
Mailing address:
  • Phone: 503-639-1171
  • Fax: 503-620-2167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0000563CS
License Number StateOR

VIII. Authorized Official

Name: CHRISTINA CUDAHY
Title or Position: PHARM MGR
Credential: RPH
Phone: 503-639-7377