1588658439 NPI number — ONTARIO PHARMACY INC

Table of content: (NPI 1588658439)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588658439 NPI number — ONTARIO PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ONTARIO PHARMACY 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:
DBA VALLEY COMPOUNDING PHARMACY
Provider Other Organization Name Type Code:
5
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:
1588658439
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
925 SW 3RD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ONTARIO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97914-2124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-889-8174
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
925 SW 3RD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ONTARIO
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97914-2124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-889-8174
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WHEATLEY
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
PHARMACIST/OWNER
Authorized Official Telephone Number:
541-889-8087

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  RP-OOOO347-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: 144808 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003355000 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3803132 . This is a "NABP#" identifier . This identifiers is of the category "OTHER".




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