Healthcare Provider Details

I. General information

NPI: 1063756393
Provider Name (Legal Business Name): SOUTH SALEM APOTHECARY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2012
Last Update Date: 03/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 COMMERCIAL ST SE
SALEM OR
97302-4110
US

IV. Provider business mailing address

990 COMMERCIAL ST SE
SALEM OR
97302-4110
US

V. Phone/Fax

Practice location:
  • Phone: 503-967-2405
  • Fax: 503-217-7940
Mailing address:
  • Phone: 503-967-2405
  • Fax: 503-217-7940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberRP0002754CS
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DIANA COURTNEY
Title or Position: OWNER
Credential:
Phone: 503-967-2405