Provider Demographics
NPI:1225338197
Name:CARMEN, WILLIS EUGENE JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:WILLIS
Middle Name:EUGENE
Last Name:CARMEN
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1128 SW 10TH DR
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-9679
Mailing Address - Country:US
Mailing Address - Phone:503-667-6626
Mailing Address - Fax:
Practice Address - Street 1:3527 SE 122ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-3401
Practice Address - Country:US
Practice Address - Phone:503-760-6688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6722183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist