Provider Demographics
NPI:1962579540
Name:SEMPERTS REXALL DRUG STORE INC
Entity type:Organization
Organization Name:SEMPERTS REXALL DRUG STORE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:LENIHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-572-5010
Mailing Address - Street 1:PO BOX 605
Mailing Address - Street 2:
Mailing Address - City:MYRTLE POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97458-0605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:735 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:MYRTLE POINT
Practice Address - State:OR
Practice Address - Zip Code:97458-1154
Practice Address - Country:US
Practice Address - Phone:541-572-5010
Practice Address - Fax:541-572-5507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ORRP0002933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR184903Medicaid
3802952OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OR184903Medicaid