Provider Demographics
NPI:1639180201
Name:TRINITY VALLEY PHARMACY, LLC
Entity Type:Organization
Organization Name:TRINITY VALLEY PHARMACY, LLC
Other - Org Name:TRINITY VALLEY PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLARISSA
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:FREE
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:541-474-9437
Mailing Address - Street 1:2001 NE FOOTHILL BLVD STE F3
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-7901
Mailing Address - Country:US
Mailing Address - Phone:541-474-9437
Mailing Address - Fax:541-955-4575
Practice Address - Street 1:2001 NE FOOTHILL BLVD STE F3
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-7901
Practice Address - Country:US
Practice Address - Phone:541-474-9437
Practice Address - Fax:541-955-4575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OR0018593336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR226575Medicaid
2079118OtherPK
OR226575Medicaid
3814147OtherOTHER ID NUMBER-COMMERCIAL NUMBER