Provider Demographics
NPI:1194708743
Name:B R WOLFE ENTERPRISES INC
Entity type:Organization
Organization Name:B R WOLFE ENTERPRISES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:O
Authorized Official - Last Name:WOLFE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:541-567-2356
Mailing Address - Street 1:PO BOX 238
Mailing Address - Street 2:945 W ORCHARD AVE
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-0238
Mailing Address - Country:US
Mailing Address - Phone:541-567-2356
Mailing Address - Fax:541-564-0378
Practice Address - Street 1:945 W ORCHARD AVE
Practice Address - Street 2:
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-1536
Practice Address - Country:US
Practice Address - Phone:541-567-2356
Practice Address - Fax:541-564-0378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR00235183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR009729Medicaid
OR1259690001Medicare ID - Type Unspecified
OR009729Medicaid