Provider Demographics
NPI:1972559979
Name:HAGGEN OPCO NORTH LLC
Entity Type:Organization
Organization Name:HAGGEN OPCO NORTH LLC
Other - Org Name:HAGGEN PHARMACY #2081
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE SENIOR VICE PRESIDENT, PH
Authorized Official - Prefix:
Authorized Official - First Name:GAETANO
Authorized Official - Middle Name:
Authorized Official - Last Name:DIPASQUA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-650-8204
Mailing Address - Street 1:2211 RIMLAND DR
Mailing Address - Street 2:STE 300
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-5664
Mailing Address - Country:US
Mailing Address - Phone:360-733-8720
Mailing Address - Fax:360-752-6437
Practice Address - Street 1:16199 BOONES FERRY RD
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-4201
Practice Address - Country:US
Practice Address - Phone:503-635-6630
Practice Address - Fax:503-635-6633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR00015143336C0003X
332B00000X
ORRP-00020793336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2150942OtherPK
2079248OtherPK
OR299096Medicaid