Provider Demographics
NPI:1043502644
Name:GUTIN, CHARLES (RPH)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:GUTIN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16303 BRYANT RD
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-4307
Mailing Address - Country:US
Mailing Address - Phone:503-636-5697
Mailing Address - Fax:503-699-7990
Practice Address - Street 1:16303 BRYANT RD
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-4307
Practice Address - Country:US
Practice Address - Phone:503-636-5697
Practice Address - Fax:503-699-7990
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-14
Last Update Date:2011-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0008922183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist