Provider Demographics
NPI:1407953805
Name:ST. CHARLES HEALTH SYSTEMS
Entity Type:Organization
Organization Name:ST. CHARLES HEALTH SYSTEMS
Other - Org Name:COMMUNITY PHARMACY AT ST. CHARLES MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:DIEGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-706-7701
Mailing Address - Street 1:2500 NE NEFF RD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6015
Mailing Address - Country:US
Mailing Address - Phone:541-706-7731
Mailing Address - Fax:541-706-6320
Practice Address - Street 1:2500 NE NEFF RD
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6015
Practice Address - Country:US
Practice Address - Phone:541-706-7731
Practice Address - Fax:541-706-6320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP0000901-CS3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269715Medicaid
368000005OtherMEDCO