Provider Demographics
NPI:1144470931
Name:CONSONUS PHARMACY SERVICES CA NORTH LLC
Entity type:Organization
Organization Name:CONSONUS PHARMACY SERVICES CA NORTH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:TAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:LAFLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:971-206-5172
Mailing Address - Street 1:4560 SE INTERNATIONAL WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-4628
Mailing Address - Country:US
Mailing Address - Phone:971-206-5205
Mailing Address - Fax:503-961-7781
Practice Address - Street 1:2148 ICON WAY STE 100
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-8803
Practice Address - Country:US
Practice Address - Phone:866-253-0048
Practice Address - Fax:503-961-7781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-29
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPH02624333600000X
3336C0004X
CA491713336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2117169OtherPK
CA1144470931Medicaid