Provider Demographics
NPI:1750787115
Name:COMMUNITY PHARMACY REDMOND
Entity type:Organization
Organization Name:COMMUNITY PHARMACY REDMOND
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:DIEGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-382-4321
Mailing Address - Street 1:1253 NW CANAL BLVD
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-1334
Mailing Address - Country:US
Mailing Address - Phone:541-516-3807
Mailing Address - Fax:541-516-3815
Practice Address - Street 1:1253 NW CANAL BLVD
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1334
Practice Address - Country:US
Practice Address - Phone:541-516-3807
Practice Address - Fax:541-516-3815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-13
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP002979CS3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2148646OtherPK
OR282848Medicaid