Provider Demographics
NPI:1982022000
Name:MIKES MERCANTILE CO
Entity Type:Organization
Organization Name:MIKES MERCANTILE CO
Other - Org Name:MIKES PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:541-336-2261
Mailing Address - Street 1:722 W HIGHWAY 20
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OR
Mailing Address - Zip Code:97391-1128
Mailing Address - Country:US
Mailing Address - Phone:541-336-2261
Mailing Address - Fax:
Practice Address - Street 1:722 W HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OR
Practice Address - Zip Code:97391-1128
Practice Address - Country:US
Practice Address - Phone:541-336-2261
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP-0002912-CS333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORRP-0002912-CSOtherOREGON STATE BOARD OF PHARMACY
ORFM4439065OtherUS DEPARTMENT OF JUSTICE DEA