MEDICARE: MEDFORD PHARMACY GROUP 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

General Provider Information

NPI Number	:	1366379372
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDFORD PHARMACY GROUP LLC

Provider Business Mailing Address
First Line	:	PO BOX B
Second Line	:
City	:	ILWACO
State	:	WA
Zip	:	98624-0167
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7591 CRATER LAKE HWY # A
Second Line	:
City	:	WHITE CITY
State	:	OR
Zip	:	97503-1663
Country	:	US
Telephone Number	:	541-826-4414
Fax Number	:	541-826-8366

Authorized Official
Title or Position	:	OWNER
Name	:	JEFFREY SHANE HARRELL
Credential	:
Telephone Number	:	360-859-8659

Provider Enumeration Date	:	05/05/2026
Last Update Date	:	05/05/2026

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