Healthcare Provider Details

I. General information

NPI: 1497758981
Provider Name (Legal Business Name): RIDDLE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 05/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 MAIN STREET
RIDDLE OR
97469
US

IV. Provider business mailing address

PO BOX 826
RIDDLE OR
97469-0826
US

V. Phone/Fax

Practice location:
  • Phone: 541-874-2406
  • Fax: 541-874-3256
Mailing address:
  • Phone: 541-874-2406
  • Fax: 541-874-3256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberRP0000483CS
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier169490
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier269347
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerMEDICAID DME

VIII. Authorized Official

Name: BLAKE RICE
Title or Position: PHARMACIST
Credential:
Phone: 541-874-2406