Provider Demographics
NPI:1114968815
Name:HUBBELL PHARMACY LLC
Entity Type:Organization
Organization Name:HUBBELL PHARMACY LLC
Other - Org Name:BROOKLYN PHARMACY INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PIC/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:HUBBELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:503-234-3488
Mailing Address - Street 1:3131 SE MILWAUKIE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202
Mailing Address - Country:US
Mailing Address - Phone:503-234-3488
Mailing Address - Fax:503-235-0373
Practice Address - Street 1:3131 SE MILWAUKIE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202
Practice Address - Country:US
Practice Address - Phone:503-234-3488
Practice Address - Fax:503-235-0373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR003663336C0003X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR020107Medicaid