Provider Demographics
NPI:1164972394
Name:SWANSTROM, KASEY ANN
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:ANN
Last Name:SWANSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 NE BEND RIVER MALL DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-7528
Mailing Address - Country:US
Mailing Address - Phone:541-385-6076
Mailing Address - Fax:541-385-9209
Practice Address - Street 1:60 NE BEND RIVER MALL DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-7528
Practice Address - Country:US
Practice Address - Phone:541-385-6076
Practice Address - Fax:541-385-9209
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT39813183500000X
OR0015679183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist