Provider Demographics
NPI:1750554622
Name:WILLAMETTE COMPOUNDING PHARMACY
Entity type:Organization
Organization Name:WILLAMETTE COMPOUNDING PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:DWIGHT
Authorized Official - Last Name:QUISENBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:503-364-3336
Mailing Address - Street 1:150 LIBERTY ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3506
Mailing Address - Country:US
Mailing Address - Phone:504-364-3336
Mailing Address - Fax:
Practice Address - Street 1:150 LIBERTY ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3506
Practice Address - Country:US
Practice Address - Phone:504-364-3336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21223336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy