Provider Demographics
NPI:1689954752
Name:BAKER CITY PHARMACY LLC
Entity Type:Organization
Organization Name:BAKER CITY PHARMACY LLC
Other - Org Name:BAKER CITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:YENCOPAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-523-6745
Mailing Address - Street 1:1920 RESORT ST
Mailing Address - Street 2:
Mailing Address - City:BAKER CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97814-2726
Mailing Address - Country:US
Mailing Address - Phone:541-523-5231
Mailing Address - Fax:
Practice Address - Street 1:1920 RESORT ST
Practice Address - Street 2:
Practice Address - City:BAKER CITY
Practice Address - State:OR
Practice Address - Zip Code:97814-2726
Practice Address - Country:US
Practice Address - Phone:541-523-5231
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-22
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ORRP00026583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2131779OtherPK