Provider Demographics
NPI:1225022841
Name:ACHTERHOF HEALTHCARE PHARMACY, LLC
Entity Type:Organization
Organization Name:ACHTERHOF HEALTHCARE PHARMACY, LLC
Other - Org Name:MANAGED HEALTHCARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:KLEMM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:541-744-1641
Mailing Address - Street 1:PO BOX 2767
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-0308
Mailing Address - Country:US
Mailing Address - Phone:541-744-1641
Mailing Address - Fax:
Practice Address - Street 1:1750 WILLOW CREEK CIR
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-9152
Practice Address - Country:US
Practice Address - Phone:541-744-1641
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-09
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR001218332B00000X, 333600000X
ORIP-0001218-CS3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR181401Medicaid
OR181400Medicaid
OR181401Medicaid
OR4563140001Medicare NSC