Provider Demographics
NPI:1013034735
Name:TRINITY VALLEY PHARMACY LLC
Entity Type:Organization
Organization Name:TRINITY VALLEY PHARMACY LLC
Other - Org Name:TRINITY VALLEY PHARMACY LLC RETAIL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLARISSA
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:FREE
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:541-474-9437
Mailing Address - Street 1:2001 NE FOOTHILL BLVD
Mailing Address - Street 2:BLDG F3
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-3947
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2001 NE FOOTHILL BLVD
Practice Address - Street 2:BLDG F3
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-3947
Practice Address - Country:US
Practice Address - Phone:541-474-9437
Practice Address - Fax:541-955-4575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OR00018853336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2079136OtherPK
OR226575Medicaid
OR226575Medicaid