Provider Demographics
NPI:1427404094
Name:SISKIYOU COMMUNITY HEALTH CENTER PHARMACY
Entity Type:Organization
Organization Name:SISKIYOU COMMUNITY HEALTH CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-471-3455
Mailing Address - Street 1:1701 NW HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1257
Mailing Address - Country:US
Mailing Address - Phone:541-471-3455
Mailing Address - Fax:541-471-9242
Practice Address - Street 1:25647 REDWOOD HWY
Practice Address - Street 2:
Practice Address - City:CAVE JUNCTION
Practice Address - State:OR
Practice Address - Zip Code:97523-9332
Practice Address - Country:US
Practice Address - Phone:541-592-4111
Practice Address - Fax:541-592-3916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-12
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP-0003008-CS3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500715326Medicaid