Provider Demographics
NPI:1073920955
Name:MARCEAU, TEDD
Entity Type:Individual
Prefix:
First Name:TEDD
Middle Name:
Last Name:MARCEAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20120 PINEBROOK BLVD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-2537
Mailing Address - Country:US
Mailing Address - Phone:541-389-5440
Mailing Address - Fax:541-389-5382
Practice Address - Street 1:20120 PINEBROOK BLVD
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-2537
Practice Address - Country:US
Practice Address - Phone:541-389-5440
Practice Address - Fax:541-389-5382
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-12
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7162183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist