Provider Demographics
NPI:1528213790
Name:CASCADE APOTHECARY INC
Entity Type:Organization
Organization Name:CASCADE APOTHECARY INC
Other - Org Name:CASCADE CUSTOM PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:VALERGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-389-3671
Mailing Address - Street 1:19550 SW AMBER MEADOW DR
Mailing Address - Street 2:STE. 170
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702
Mailing Address - Country:US
Mailing Address - Phone:541-389-3671
Mailing Address - Fax:541-385-6260
Practice Address - Street 1:19550 AMBER MEADOW DR STE 170
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3527
Practice Address - Country:US
Practice Address - Phone:541-389-3671
Practice Address - Fax:541-728-0988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-01
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP0002541CS333600000X
3336C0003X
ORRP-002541-CS3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146844OtherPK
OR500675098Medicaid