Provider Demographics
NPI:1871946376
Name:ROGUE COMMUNITY HEALTH
Entity type:Organization
Organization Name:ROGUE COMMUNITY HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY, AO
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:CERVAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:541-200-6859
Mailing Address - Street 1:900 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7136
Mailing Address - Country:US
Mailing Address - Phone:541-200-6859
Mailing Address - Fax:541-622-0360
Practice Address - Street 1:8385 DIVISION RD
Practice Address - Street 2:
Practice Address - City:WHITE CITY
Practice Address - State:OR
Practice Address - Zip Code:97503-1176
Practice Address - Country:US
Practice Address - Phone:541-500-0989
Practice Address - Fax:541-622-0360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-20
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ORRP-0003210-CS3336C0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2163704OtherPK
OR500718132Medicaid