Provider Demographics
NPI:1871643379
Name:PHARMACY EXPRESS #74
Entity Type:Organization
Organization Name:PHARMACY EXPRESS #74
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF NON-FOOD
Authorized Official - Prefix:
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:NESTEGARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-251-0466
Mailing Address - Street 1:615 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-9199
Mailing Address - Country:US
Mailing Address - Phone:541-251-0466
Mailing Address - Fax:541-412-0002
Practice Address - Street 1:150 OROYAN ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404
Practice Address - Country:US
Practice Address - Phone:541-469-3113
Practice Address - Fax:541-412-0002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR=========Medicare UPIN