Basic Information
| Provider Information | |||||||||
| NPI: | 1689023780 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KLAMATH HEALTH PARTNERSHIP INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KLAMATH OPEN DOOR PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2074 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976013372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418518110 | ||||||||
| FaxNumber: | 5418510190 | ||||||||
| Practice Location | |||||||||
| Address1: | 2074 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976013372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418518110 | ||||||||
| FaxNumber: | 5418510190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2016 | ||||||||
| LastUpdateDate: | 08/06/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MASTERS | ||||||||
| AuthorizedOfficialFirstName: | JEANA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DO/CREDENTIALIST | ||||||||
| AuthorizedOfficialTelephone: | 5418518110 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 500719898 | 05 | OR | MEDICAID |