Provider Demographics
NPI:1326353848
Name:FOUR RIVERS CORRECTIONAL PHARMACY
Entity Type:Organization
Organization Name:FOUR RIVERS CORRECTIONAL PHARMACY
Other - Org Name:SNAKE RIVER CORRECTIONAL INSTITUTION-ODOC (REMOVE)
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF PHARMACY OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROB
Authorized Official - Middle Name:C
Authorized Official - Last Name:NUTT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:541-709-1958
Mailing Address - Street 1:2757 22ND ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302
Mailing Address - Country:US
Mailing Address - Phone:503-378-5449
Mailing Address - Fax:503-378-8902
Practice Address - Street 1:88 SW 3RD AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914
Practice Address - Country:US
Practice Address - Phone:503-986-6969
Practice Address - Fax:541-889-0027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-09
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336I0012XSuppliersPharmacyInstitutional PharmacyGroup - Single Specialty