Provider Demographics
NPI:1255303749
Name:LIDEL, REBECCA JANETTE (RPH)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:JANETTE
Last Name:LIDEL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17323 SW JAY STREET
Mailing Address - Street 2:APT. 303
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97003
Mailing Address - Country:US
Mailing Address - Phone:406-241-1824
Mailing Address - Fax:
Practice Address - Street 1:17323 SW JAY STREET
Practice Address - Street 2:APT. 303
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97003
Practice Address - Country:US
Practice Address - Phone:406-241-1824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2937183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist