Provider Demographics
NPI:1013063619
Name:WSG CORP
Entity Type:Organization
Organization Name:WSG CORP
Other - Org Name:ROGUE RIVER PHARMACY #1138
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKESLEE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:360-213-2236
Mailing Address - Street 1:916 W EVERGREEN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-3035
Mailing Address - Country:US
Mailing Address - Phone:360-213-2236
Mailing Address - Fax:360-213-2238
Practice Address - Street 1:506 E MAIN STREET
Practice Address - Street 2:
Practice Address - City:ROGUE RIVER
Practice Address - State:OR
Practice Address - Zip Code:97537
Practice Address - Country:US
Practice Address - Phone:541-582-0559
Practice Address - Fax:541-582-3045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR241898Medicaid
OR3842665OtherNCPDP
OR3842665OtherNCPDP
OR5224870002Medicare NSC
OR3842665OtherNCPDP