Healthcare Provider Details

I. General information

NPI: 1760859367
Provider Name (Legal Business Name): QUISENBERRY HEALTH SYSTEM PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2015
Last Update Date: 08/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 LIBERTY ST SE
SALEM OR
97301-3506
US

IV. Provider business mailing address

150 LIBERTY ST SE
SALEM OR
97301-3506
US

V. Phone/Fax

Practice location:
  • Phone: 503-364-3336
  • Fax:
Mailing address:
  • Phone: 503-364-3336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberIP-0002261-CS
License Number StateOR

VIII. Authorized Official

Name: STEVE QUISENBERRY
Title or Position: OWNER
Credential:
Phone: 503-364-3336