1477711802 NPI number — CONFEDERATED TRIBES OF THE GRAND RONDE COMMUNITY OF OREGON

Table of content: (NPI 1477711802)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477711802 NPI number — CONFEDERATED TRIBES OF THE GRAND RONDE COMMUNITY OF OREGON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONFEDERATED TRIBES OF THE GRAND RONDE COMMUNITY OF OREGON
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CONFEDERATED TRIBES OF GRAND RONDE HEALTH & WELLNESS CENTER PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477711802
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9605 GRAND RONDE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RONDE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97347-9712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-879-3013
Provider Business Mailing Address Fax Number:
503-879-2013

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9605 GRAND RONDE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RONDE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97347-9712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-879-2342
Provider Business Practice Location Address Fax Number:
503-879-2030
Provider Enumeration Date:
06/02/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WRIGHT
Authorized Official First Name:
LINCOLN
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY DIRECTOR
Authorized Official Telephone Number:
503-879-2299

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2079588 . This is a "PK" identifier . This identifiers is of the category "OTHER".