Provider Demographics
NPI:1154414597
Name:TRINITY COMPOUNDING PHARMACY
Entity type:Organization
Organization Name:TRINITY COMPOUNDING PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF CLINICAL OFFICER, PIC
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-684-9352
Mailing Address - Street 1:1515 OAK ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-4790
Mailing Address - Country:US
Mailing Address - Phone:541-684-9352
Mailing Address - Fax:541-684-0858
Practice Address - Street 1:1515 OAK ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4790
Practice Address - Country:US
Practice Address - Phone:541-684-9352
Practice Address - Fax:541-684-0858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPMP-792333600000X
ORRP-00015643336C0003X
WAPHNR.FO.603123183336C0004X
AKPHAO11793336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227829Medicaid
2079479OtherPK
AK1581038Medicaid
WA2096620Medicaid