Provider Demographics
NPI:1427197201
Name:BANDON PHARMACY
Entity Type:Organization
Organization Name:BANDON PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SWENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-347-2222
Mailing Address - Street 1:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:BANDON
Mailing Address - State:OR
Mailing Address - Zip Code:97411-0369
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1225 OREGON AVE
Practice Address - Street 2:
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411-0369
Practice Address - Country:US
Practice Address - Phone:541-347-2222
Practice Address - Fax:541-347-4241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ORRP00001323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3807041OtherOTHER ID NUMBER-COMMERCIAL NUMBER
OR163063Medicaid
3807041OtherOTHER ID NUMBER