Provider Demographics
NPI:1023438439
Name:SUNRIVER PHARMACY
Entity type:Organization
Organization Name:SUNRIVER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:GILBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-621-1953
Mailing Address - Street 1:PO BOX 4789
Mailing Address - Street 2:
Mailing Address - City:SUNRIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97707-1789
Mailing Address - Country:US
Mailing Address - Phone:541-621-1953
Mailing Address - Fax:
Practice Address - Street 1:56890 VENTURE LANE
Practice Address - Street 2:
Practice Address - City:SUNRIVER
Practice Address - State:OR
Practice Address - Zip Code:97707
Practice Address - Country:US
Practice Address - Phone:541-621-1953
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy