Provider Demographics
NPI:1598831257
Name:GOOD SHEPHERD MEDICAL SERVICE CORP
Entity Type:Organization
Organization Name:GOOD SHEPHERD MEDICAL SERVICE CORP
Other - Org Name:GOOD SHEPHERD CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR OF PHCY SVCS
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH MBA
Authorized Official - Phone:541-667-3647
Mailing Address - Street 1:610 NW 11TH ST
Mailing Address - Street 2:STE E04
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-6601
Mailing Address - Country:US
Mailing Address - Phone:541-667-3652
Mailing Address - Fax:541-667-3649
Practice Address - Street 1:610 NW 11TH ST
Practice Address - Street 2:STE E04
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-6601
Practice Address - Country:US
Practice Address - Phone:541-667-3652
Practice Address - Fax:541-667-3649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP0001660CS3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500400205Medicaid
2078900OtherPK