Provider Demographics
NPI:1154433167
Name:DAVID JORGENSEN
Entity type:Organization
Organization Name:DAVID JORGENSEN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:JORGENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-343-8861
Mailing Address - Street 1:1755 COBURG RD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401
Mailing Address - Country:US
Mailing Address - Phone:541-343-8861
Mailing Address - Fax:541-465-1392
Practice Address - Street 1:1755 COBURG RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401
Practice Address - Country:US
Practice Address - Phone:541-343-8861
Practice Address - Fax:541-465-1392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR00182332B00000X, 3336C0003X
333600000X, 3336C0003X, 3336L0003X, 3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1180250001OtherDMERC
OR170922Medicaid
3801657OtherOTHER ID NUMBER-COMMERCIAL NUMBER
3801657OtherOTHER ID NUMBER-COMMERCIAL NUMBER
3801657OtherOTHER ID NUMBER-COMMERCIAL NUMBER