Healthcare Provider Details

I. General information

NPI: 1962579540
Provider Name (Legal Business Name): SEMPERTS REXALL DRUG STORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 SPRUCE ST
MYRTLE POINT OR
97458-1154
US

IV. Provider business mailing address

PO BOX 605
MYRTLE POINT OR
97458-0605
US

V. Phone/Fax

Practice location:
  • Phone: 541-572-5010
  • Fax: 541-572-5507
Mailing address:
  • Phone:
  • Fax:

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 NumberRP000293
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier184903
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier3802952
Identifier TypeOTHER
Identifier State
Identifier IssuerNCPDP PROVIDER IDENTIFICATION NUMBER

VIII. Authorized Official

Name: LARRY LENIHAN
Title or Position: PRESIDENT
Credential:
Phone: 541-572-5010