Provider Demographics
NPI:1942711353
Name:MAHANT LLC
Entity Type:Organization
Organization Name:MAHANT LLC
Other - Org Name:CORNER DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:TRUSHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-752-4459
Mailing Address - Street 1:29670 ELLENSBURG AVE
Mailing Address - Street 2:
Mailing Address - City:GOLD BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97444-8701
Mailing Address - Country:US
Mailing Address - Phone:541-247-4544
Mailing Address - Fax:541-247-2604
Practice Address - Street 1:29670 ELLENSBURG AVE
Practice Address - Street 2:
Practice Address - City:GOLD BEACH
Practice Address - State:OR
Practice Address - Zip Code:97444-8701
Practice Address - Country:US
Practice Address - Phone:541-247-4544
Practice Address - Fax:541-247-2604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-12
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ORRP-2183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2172045OtherPK
OR500739552Medicaid