Provider Demographics
NPI:1558516716
Name:HURLEY, CHARLES DERRIS (RPH)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:DERRIS
Last Name:HURLEY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 MAIN ST
Mailing Address - Street 2:SAFEWAY PHARMACY
Mailing Address - City:SWEET HOME
Mailing Address - State:OR
Mailing Address - Zip Code:97386
Mailing Address - Country:US
Mailing Address - Phone:541-367-0675
Mailing Address - Fax:541-367-0678
Practice Address - Street 1:1540 MAIN ST
Practice Address - Street 2:SAFEWAY PHARMACY
Practice Address - City:SWEET HOME
Practice Address - State:OR
Practice Address - Zip Code:97386-1614
Practice Address - Country:US
Practice Address - Phone:541-367-0675
Practice Address - Fax:541-367-0678
Is Sole Proprietor?:No
Enumeration Date:2008-12-01
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8111183500000X
OR081111835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist