1508962317 NPI number — TIFFANY-DAVIS DRUG CO.

Table of content: DR. EARL RANDY CRAVEN MD (NPI 1457354821)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508962317 NPI number — TIFFANY-DAVIS DRUG CO.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIFFANY-DAVIS DRUG CO.
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:
1508962317
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
960 OAK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EUGENE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97401-3106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-342-2148
Provider Business Mailing Address Fax Number:
541-686-8305

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
960 OAK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97401-3106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-686-8304
Provider Business Practice Location Address Fax Number:
541-686-8522
Provider Enumeration Date:
09/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ENGEL
Authorized Official First Name:
DALE
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
541-342-2148

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  NPA0006963 , 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: 198721 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3801669 . This is a "NABP" identifier . This identifiers is of the category "OTHER".




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