Healthcare Provider Details

I. General information

NPI: 1558516716
Provider Name (Legal Business Name): CHARLES DERRIS HURLEY R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2008
Last Update Date: 03/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 MAIN ST SAFEWAY PHARMACY
SWEET HOME OR
97386-1614
US

IV. Provider business mailing address

1540 MAIN ST SAFEWAY PHARMACY
SWEET HOME OR
97386
US

V. Phone/Fax

Practice location:
  • Phone: 541-367-0675
  • Fax: 541-367-0678
Mailing address:
  • Phone: 541-367-0675
  • Fax: 541-367-0678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8111
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number08111
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: