Healthcare Provider Details

I. General information

NPI: 1265572150
Provider Name (Legal Business Name): ROGUE VALLEY MANOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 04/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 MIRA MAR AVE
MEDFORD OR
97504-5520
US

IV. Provider business mailing address

1250 MIRA MAR AVE
MEDFORD OR
97504-5520
US

V. Phone/Fax

Practice location:
  • Phone: 541-857-7361
  • Fax: 541-857-7362
Mailing address:
  • Phone: 541-857-7361
  • Fax: 541-857-7362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberRP0000882
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: FRED MILLAN
Title or Position: DIRECTOR OF PHARMACY
Credential: RPH
Phone: 541-857-7361