Provider Demographics
NPI:1275698458
Name:ROSE CITY PHARMACY
Entity Type:Organization
Organization Name:ROSE CITY PHARMACY
Other - Org Name:GATEWAY MEDICAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:CAO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-254-7383
Mailing Address - Street 1:1125 NE 99TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-9428
Mailing Address - Country:US
Mailing Address - Phone:503-254-7383
Mailing Address - Fax:503-254-4568
Practice Address - Street 1:1125 NE 99TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-9428
Practice Address - Country:US
Practice Address - Phone:503-254-7383
Practice Address - Fax:503-254-4568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacyGroup - Multi-Specialty
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2161521Medicaid
OR170080Medicaid
OR133412Medicare PIN