Healthcare Provider Details

I. General information

NPI: 1841606662
Provider Name (Legal Business Name): REDMOND LONG TERM CARE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 NW 5TH ST STE A
REDMOND OR
97756-1627
US

IV. Provider business mailing address

424 NW 5TH STREET SUITE A
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 Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberIP0002253CS
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number StateNULL

VIII. Authorized Official

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