Provider Demographics
NPI:1356555460
Name:HIGHLAND PARK PHARMACY LLC
Entity type:Organization
Organization Name:HIGHLAND PARK PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMONDSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:541-526-1771
Mailing Address - Street 1:424 NW 5TH STREET
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756
Mailing Address - Country:US
Mailing Address - Phone:541-526-1771
Mailing Address - Fax:541-504-5476
Practice Address - Street 1:424 NW 5TH ST
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756
Practice Address - Country:US
Practice Address - Phone:541-526-1771
Practice Address - Fax:541-504-5476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X
ORRP00023943336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278755Medicaid
2079550OtherPK
OR279070Medicaid