Provider Demographics
NPI:1225190408
Name:CREDENA HEALTH LLC
Entity Type:Organization
Organization Name:CREDENA HEALTH LLC
Other - Org Name:CREDENA HEALTH PHARMACY ST VINCENT
Other - Org Type:Other Name
Authorized Official - Title/Position:AVP/SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:SKAFI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-650-3396
Mailing Address - Street 1:PO BOX 2704
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-2704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9155 SW BARNES RD STE 102
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6625
Practice Address - Country:US
Practice Address - Phone:503-216-2630
Practice Address - Fax:503-216-2637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR222380Medicaid