1093095259 NPI number — DR. JEREMY BROWN PHARMD

Table of content: (NPI 1538236179)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093095259 NPI number — DR. JEREMY BROWN PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROWN
Provider First Name:
JEREMY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1093095259
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1775 THOMPSON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COOS BAY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97420-2198
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-269-8489
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1775 THOMPSON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COOS BAY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97420-2198
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-269-8489
Provider Business Practice Location Address Fax Number:
912-265-0956
Provider Enumeration Date:
08/19/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  RPH025976 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 183500000X , with the licence number: RPH-0016701 , 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: RPH025976 . This is a "GEORGIA STATE PHARMACY LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: RPH-0016701 . This is a "OREGON BOARD OF PHARMACY" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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