Provider Demographics
NPI:1063495596
Name:PHOENIX DOWNTOWN PHARMACY LLC
Entity Type:Organization
Organization Name:PHOENIX DOWNTOWN PHARMACY LLC
Other - Org Name:PHOENIX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:EGENDOERFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-301-1473
Mailing Address - Street 1:PO BOX 817
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:OR
Mailing Address - Zip Code:97535-0817
Mailing Address - Country:US
Mailing Address - Phone:541-301-1473
Mailing Address - Fax:503-549-8717
Practice Address - Street 1:404 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:OR
Practice Address - Zip Code:97535-9632
Practice Address - Country:US
Practice Address - Phone:541-535-1561
Practice Address - Fax:541-535-3015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-29
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ORRP-0000299-CS3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140394OtherPK
2140394OtherPK