=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003837980
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHERIDAN PHARMACY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2006
-----------------------------------------------------
Last Update Date | 12/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 E MAIN ST
-----------------------------------------------------
City | SHERIDAN
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97378-1828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-843-2422
-----------------------------------------------------
Fax | 503-843-5043
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 916 W EVERGREEN BLVD
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98660-3035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-213-2236
-----------------------------------------------------
Fax | 360-213-2238
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF PHARMACY
-----------------------------------------------------
Name | KRISTI VEIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 503-507-6073
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | RP-0000500-CS
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------