Provider Demographics
NPI:1073903563
Name:PANTHAPATTU, JOVIN V (PHARMD BCACP)
Entity Type:Individual
Prefix:DR
First Name:JOVIN
Middle Name:V
Last Name:PANTHAPATTU
Suffix:
Gender:M
Credentials:PHARMD BCACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7320 SW HUNZIKER RD STE 300
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-2302
Mailing Address - Country:US
Mailing Address - Phone:035-941-3033
Mailing Address - Fax:
Practice Address - Street 1:178 SW 2ND AVE
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-4152
Practice Address - Country:US
Practice Address - Phone:503-416-4547
Practice Address - Fax:503-416-4553
Is Sole Proprietor?:No
Enumeration Date:2015-02-04
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-00165441835P2201X
ORRPH-0016544-P1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500758246Medicaid