Provider Demographics
NPI:1952358780
Name:SOUTH SALEM APOTHECARY, LLC
Entity Type:Organization
Organization Name:SOUTH SALEM APOTHECARY, LLC
Other - Org Name:SOUTH SALEM APOTHECARY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:COURTNEY
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:503-967-2407
Mailing Address - Street 1:990 COMMERCIAL ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4110
Mailing Address - Country:US
Mailing Address - Phone:503-967-2407
Mailing Address - Fax:503-217-7940
Practice Address - Street 1:990 COMMERCIAL ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4110
Practice Address - Country:US
Practice Address - Phone:503-967-2407
Practice Address - Fax:503-217-7940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP0002199CS333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3841865OtherOTHER ID NUMBER
OR231440Medicaid