Provider Demographics
NPI:1881106961
Name:HOME TOWN DRUGS OF ROSEBURG INC
Entity type:Organization
Organization Name:HOME TOWN DRUGS OF ROSEBURG INC
Other - Org Name:
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 STE 210
Mailing Address - Street 2:
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:541-464-4530
Practice Address - Street 1:1813 W HARVARD AVE STE 210
Practice Address - Street 2:
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:541-464-4530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-30
Last Update Date:2024-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR3842831OtherNCPDP
OR274394Medicaid