Provider Demographics
NPI:1811349434
Name:PHARMBLUE OREGON LLC
Entity type:Organization
Organization Name:PHARMBLUE OREGON LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-779-4720
Mailing Address - Street 1:40 PENNWOOD PL
Mailing Address - Street 2:SUITE 300
Mailing Address - City:WARRENDALE
Mailing Address - State:PA
Mailing Address - Zip Code:15086-6526
Mailing Address - Country:US
Mailing Address - Phone:724-779-4720
Mailing Address - Fax:724-779-4721
Practice Address - Street 1:140 S HOLLY ST
Practice Address - Street 2:SUITE 1131
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-3113
Practice Address - Country:US
Practice Address - Phone:800-967-6816
Practice Address - Fax:855-570-4895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-07
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336S0011X, 333600000X
ORRP-0003221-CS3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1811349434Medicaid
2160991OtherPK