Provider Demographics
NPI:1821292707
Name:HOME TOWN DRUGS OF ROSEBURG INC
Entity type:Organization
Organization Name:HOME TOWN DRUGS OF ROSEBURG INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:HARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-244-5984
Mailing Address - Street 1:1813 W HARVARD AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-2709
Mailing Address - Country:US
Mailing Address - Phone:541-229-1112
Mailing Address - Fax:541-229-1112
Practice Address - Street 1:1813 W HARVARD AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2709
Practice Address - Country:US
Practice Address - Phone:541-229-1112
Practice Address - Fax:541-229-1112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2024-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP00024083336C0003X, 3336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3842831OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OR274394Medicaid
OR274394Medicaid
3842831OtherNCPDP PROVIDER IDENTIFICATION NUMBER