Provider Demographics
NPI:1144767427
Name:PRESTIGE PROFESSIONAL PHARMACY
Entity Type:Organization
Organization Name:PRESTIGE PROFESSIONAL PHARMACY
Other - Org Name:PRESTIGE PROFESSIONAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/AO
Authorized Official - Prefix:
Authorized Official - First Name:CLOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:PHARMACY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-542-0733
Mailing Address - Street 1:11723 NE GLISAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-2141
Mailing Address - Country:US
Mailing Address - Phone:866-660-2626
Mailing Address - Fax:888-299-2770
Practice Address - Street 1:11723 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-2141
Practice Address - Country:US
Practice Address - Phone:866-660-2626
Practice Address - Fax:888-299-2770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-25
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
ORRP00032513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2167382OtherPK