Provider Demographics
NPI:1003921453
Name:ROGUE RX INC.
Entity Type:Organization
Organization Name:ROGUE RX INC.
Other - Org Name:CASCADE NATURAL HEALTH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:N
Authorized Official - Last Name:DONOVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-826-4414
Mailing Address - Street 1:7591 A CRATER LAKE HWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:WHITE CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97503
Mailing Address - Country:US
Mailing Address - Phone:541-826-4414
Mailing Address - Fax:541-826-8366
Practice Address - Street 1:7591 A CRATER LAKE HWY
Practice Address - Street 2:SUITE A
Practice Address - City:WHITE CITY
Practice Address - State:OR
Practice Address - Zip Code:97503
Practice Address - Country:US
Practice Address - Phone:541-826-4414
Practice Address - Fax:541-826-8366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
ORRP-0000588-CS3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR043229Medicaid
OR3916680001Medicare ID - Type Unspecified