Healthcare Provider Details

I. General information

NPI: 1356555460
Provider Name (Legal Business Name): HIGHLAND PARK PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 10/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 NW 5TH ST
REDMOND OR
97756
US

IV. Provider business mailing address

424 NW 5TH STREET
REDMOND OR
97756
US

V. Phone/Fax

Practice location:
  • Phone: 541-526-1771
  • Fax: 541-504-5476
Mailing address:
  • Phone: 541-526-1771
  • Fax: 541-504-5476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberRP0002394
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MIKE EDMONDSON
Title or Position: OWNER
Credential: RPH
Phone: 541-526-1771