Provider Demographics
NPI:1760881791
Name:PROVIDENCE HOOD RIVER MEMORIAL HOSPITAL PHARMACY
Entity Type:Organization
Organization Name:PROVIDENCE HOOD RIVER MEMORIAL HOSPITAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNI
Authorized Official - Middle Name:R
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:541-387-8245
Mailing Address - Street 1:810 12TH ST
Mailing Address - Street 2:
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031-1587
Mailing Address - Country:US
Mailing Address - Phone:541-387-6338
Mailing Address - Fax:541-387-8213
Practice Address - Street 1:810 12TH ST
Practice Address - Street 2:PHARMACY
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-1587
Practice Address - Country:US
Practice Address - Phone:541-387-6338
Practice Address - Fax:541-387-8213
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH AND SERVICES - OREGON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-14
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP-0000830-CS3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR210241Medicaid
OR38131800Medicare PIN
WA3300415Medicaid