MEDICARE: PHOENIX DOWNTOWN PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	RP-0000299-CS	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2140394	OTHER		PK

General Provider Information

NPI Number	:	1063495596
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX DOWNTOWN PHARMACY LLC

Provider Business Mailing Address
First Line	:	PO BOX 817
Second Line	:
City	:	PHOENIX
State	:	OR
Zip	:	97535-0817
Country	:	US
Telephone Number	:	541-301-1473
Fax Number	:	503-549-8717

Provider Business Practice Location Address
First Line	:	404 N MAIN ST
Second Line	:
City	:	PHOENIX
State	:	OR
Zip	:	97535-9632
Country	:	US
Telephone Number	:	541-535-1561
Fax Number	:	541-535-3015

Authorized Official
Title or Position	:	OWNER
Name	:	BENJAMIN EGENDOERFER
Credential	:
Telephone Number	:	541-301-1473

Provider Enumeration Date	:	11/29/2005
Last Update Date	:	05/06/2014

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