MEDICARE: RXMEDLAB 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	3336S0011X	Specialty Pharmacy	2763	OR
2	3336C0004X	Compounding Pharmacy	2763	OR

General Provider Information

NPI Number	:	1528306081
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RXMEDLAB PHARMACY , LLC

Provider Business Mailing Address
First Line	:	162 NE BEACON DR
Second Line	:	SUITE # 109
City	:	GRANTS PASS
State	:	OR
Zip	:	97526-4260
Country	:	US
Telephone Number	:	541-474-3784
Fax Number	:

Provider Business Practice Location Address
First Line	:	162 NE BEACON DR
Second Line	:	SUITE # 109
City	:	GRANTS PASS
State	:	OR
Zip	:	97526-4260
Country	:	US
Telephone Number	:	541-474-3784
Fax Number	:

Authorized Official
Title or Position	:	PHARMACIST / OWNER
Name	:	MR. DENNIS RAY CLARK
Credential	:	R.PH.
Telephone Number	:	541-474-3784

Provider Enumeration Date	:	01/17/2013
Last Update Date	:	01/17/2013

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Directions to “RXMEDLAB PHARMACY , LLC ” Practice Location

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