Healthcare Provider Details

I. General information

NPI: 1811349434
Provider Name (Legal Business Name): PHARMBLUE OREGON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 03/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 S HOLLY ST SUITE 1131
MEDFORD OR
97501-3113
US

IV. Provider business mailing address

40 PENNWOOD PL SUITE 300
WARRENDALE PA
15086-6526
US

V. Phone/Fax

Practice location:
  • Phone: 800-967-6816
  • Fax: 855-570-4895
Mailing address:
  • Phone: 724-779-4720
  • Fax: 724-779-4721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberRP-0003221-CS
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL NELSON
Title or Position: CEO
Credential:
Phone: 724-779-4720