Provider Demographics
NPI:1023483823
Name:CENTRAL OREGON PHARMACY AND COMPOUNDING
Entity type:Organization
Organization Name:CENTRAL OREGON PHARMACY AND COMPOUNDING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER-PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-548-1066
Mailing Address - Street 1:655 NW GREENWOOD AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-1672
Mailing Address - Country:US
Mailing Address - Phone:541-548-1066
Mailing Address - Fax:541-548-1067
Practice Address - Street 1:655 NW GREENWOOD AVE STE 1
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1672
Practice Address - Country:US
Practice Address - Phone:541-548-1066
Practice Address - Fax:541-548-1067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-04
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 333600000X
ORRP-0003153-CS3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2159559OtherPK
OR500705645Medicaid