Provider Demographics
NPI:1235471343
Name:PHOENIX DOWNTOWN PHARMACY, LLC
Entity Type:Organization
Organization Name:PHOENIX DOWNTOWN PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
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 1:116 MEADOW VIEW DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:OR
Mailing Address - Zip Code:97535-9431
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
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:541-301-1473
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
ORRP 0000299 CS333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies