Provider Demographics
NPI:1760859367
Name:QUISENBERRY HEALTH SYSTEM PHARMACY, LLC
Entity Type:Organization
Organization Name:QUISENBERRY HEALTH SYSTEM PHARMACY, LLC
Other - Org Name:QUISENBERRY HEALTH SYSTEM PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:QUISENBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-364-3336
Mailing Address - Street 1:150 LIBERTY ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3506
Mailing Address - Country:US
Mailing Address - Phone:503-364-3336
Mailing Address - Fax:
Practice Address - Street 1:148 LIBERTY ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3506
Practice Address - Country:US
Practice Address - Phone:503-364-3336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-31
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORIP-0002261-CS3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2153772OtherPK