MEDICARE: J & I BLACK, INC.

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	183500000X	Pharmacist	RPH-7673	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	3811557	OTHER	OR	NCPDP #

General Provider Information

NPI Number	:	1790729077
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	J & I BLACK, INC.

Provider Business Mailing Address
First Line	:	PO BOX 309
Second Line	:
City	:	SUTHERLIN
State	:	OR
Zip	:	97479-0309
Country	:	US
Telephone Number	:	541-459-2712
Fax Number	:	541-459-9129

Provider Business Practice Location Address
First Line	:	113 E CENTRAL AVE
Second Line	:
City	:	SUTHERLIN
State	:	OR
Zip	:	97479-9556
Country	:	US
Telephone Number	:	541-459-2712
Fax Number	:	541-459-9129

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. IAN L BLACK
Credential	:	B.S., R.PH.
Telephone Number	:	541-459-2712

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	08/22/2020

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Directions to “J & I BLACK, INC. ” Practice Location

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