Provider Demographics
NPI:1114312451
Name:WILLAMETTE PAIN & SPINE CENTER PC
Entity Type:Organization
Organization Name:WILLAMETTE PAIN & SPINE CENTER PC
Other - Org Name:SUNNYSIDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR, LICENSING & THIRD PARTY
Authorized Official - Prefix:
Authorized Official - First Name:TAMMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MISKIMINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-572-0009
Mailing Address - Street 1:1620 W. NORTHWEST HWY
Mailing Address - Street 2:STE. 100
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051
Mailing Address - Country:US
Mailing Address - Phone:817-572-0009
Mailing Address - Fax:817-720-1039
Practice Address - Street 1:10001 SE SUNNYSIDE RD STE 100A
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9728
Practice Address - Country:US
Practice Address - Phone:503-343-9363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-03
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP0003062CS3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2151143OtherPK