Provider Demographics
NPI:1265695456
Name:FAIRLEY'S RX INC
Entity type:Organization
Organization Name:FAIRLEY'S RX INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:425-802-1891
Mailing Address - Street 1:7206 NE SANDY BLVD
Mailing Address - Street 2:STE:B
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-5741
Mailing Address - Country:US
Mailing Address - Phone:503-281-7500
Mailing Address - Fax:503-281-7505
Practice Address - Street 1:7206 NE SANDY BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213
Practice Address - Country:US
Practice Address - Phone:503-281-7500
Practice Address - Fax:503-281-1211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-08
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORIP0002182CS3336L0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR279296Medicaid
OR279296Medicaid