1003921453 NPI number — ROGUE RX INC.

Table of content: OBIAMAKA OBIANUJU OJI FNP (NPI 1609299775)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003921453 NPI number — ROGUE RX INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROGUE RX INC.
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:
Provider Other Organization Name Type Code:
6
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:
1003921453
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7591 A CRATER LAKE HWY
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
WHITE CITY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-826-4414
Provider Business Mailing Address Fax Number:
541-826-8366

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7591 A CRATER LAKE HWY
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
WHITE CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-826-4414
Provider Business Practice Location Address Fax Number:
541-826-8366
Provider Enumeration Date:
08/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DONOVAN
Authorized Official First Name:
COREY
Authorized Official Middle Name:
N
Authorized Official Title or Position:
GENERAL MANAGER
Authorized Official Telephone Number:
541-826-4414

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: RP-0000588-CS , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 043229 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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