Provider Demographics
NPI:1083787436
Name:PENG, NISSE (RPH, PHARMD)
Entity Type:Individual
Prefix:
First Name:NISSE
Middle Name:
Last Name:PENG
Suffix:
Gender:F
Credentials:RPH, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 NW LOVEJOY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2785
Mailing Address - Country:US
Mailing Address - Phone:503-205-6751
Mailing Address - Fax:503-205-6750
Practice Address - Street 1:1303 NW LOVEJOY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2785
Practice Address - Country:US
Practice Address - Phone:503-205-6751
Practice Address - Fax:503-205-6750
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-11103183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist