Provider Demographics
NPI:1528306081
Name:RXMEDLAB PHARMACY , LLC
Entity type:Organization
Organization Name:RXMEDLAB PHARMACY , LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST / OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:541-474-3784
Mailing Address - Street 1:162 NE BEACON DR
Mailing Address - Street 2:SUITE # 109
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-4260
Mailing Address - Country:US
Mailing Address - Phone:541-474-3784
Mailing Address - Fax:
Practice Address - Street 1:162 NE BEACON DR
Practice Address - Street 2:SUITE # 109
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-4260
Practice Address - Country:US
Practice Address - Phone:541-474-3784
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-17
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27633336S0011X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy