Provider Demographics
NPI:1477711802
Name:CONFEDERATED TRIBES OF THE GRAND RONDE COMMUNITY OF OREGON
Entity Type:Organization
Organization Name:CONFEDERATED TRIBES OF THE GRAND RONDE COMMUNITY OF OREGON
Other - Org Name:CONFEDERATED TRIBES OF GRAND RONDE HEALTH & WELLNESS CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LINCOLN
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:503-879-2299
Mailing Address - Street 1:9605 GRAND RONDE RD
Mailing Address - Street 2:
Mailing Address - City:GRAND RONDE
Mailing Address - State:OR
Mailing Address - Zip Code:97347-9712
Mailing Address - Country:US
Mailing Address - Phone:503-879-3013
Mailing Address - Fax:503-879-2013
Practice Address - Street 1:9605 GRAND RONDE RD
Practice Address - Street 2:
Practice Address - City:GRAND RONDE
Practice Address - State:OR
Practice Address - Zip Code:97347-9712
Practice Address - Country:US
Practice Address - Phone:503-879-2342
Practice Address - Fax:503-879-2030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2079588OtherPK