Provider Demographics
NPI:1457411779
Name:GRANTS PASS PHARMACY, INC.
Entity type:Organization
Organization Name:GRANTS PASS PHARMACY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BELCHER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:541-476-4262
Mailing Address - Street 1:414 SW 6TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-2810
Mailing Address - Country:US
Mailing Address - Phone:541-476-4262
Mailing Address - Fax:541-474-1443
Practice Address - Street 1:414 SW 6TH ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-2810
Practice Address - Country:US
Practice Address - Phone:541-476-4262
Practice Address - Fax:541-474-1443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR002253336C0004X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR076356Medicaid
OR0413170001Medicare NSC