Provider Demographics
NPI:1699838227
Name:OREGON HEALTHCARE PHARMACY SERVICES INC
Entity Type:Organization
Organization Name:OREGON HEALTHCARE PHARMACY SERVICES INC
Other - Org Name:OREGON HEALTHCARE PHARMACY SERVICES INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:MONGAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:815-732-1422
Mailing Address - Street 1:1100 PINES RD
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:IL
Mailing Address - Zip Code:61061-9653
Mailing Address - Country:US
Mailing Address - Phone:815-732-1422
Mailing Address - Fax:815-732-1532
Practice Address - Street 1:1100 PINES RD
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:IL
Practice Address - Zip Code:61061-9653
Practice Address - Country:US
Practice Address - Phone:815-732-1422
Practice Address - Fax:815-732-1532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054.016954333600000X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2020977OtherPK
IL=========Medicaid
IL=========Medicaid