Provider Demographics
NPI:1275060162
Name:AGR, CHANCHAL
Entity Type:Individual
Prefix:
First Name:CHANCHAL
Middle Name:
Last Name:AGR
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 1:4300 GOODPASTURE LOOP APT 39
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-1415
Mailing Address - Country:US
Mailing Address - Phone:541-908-2357
Mailing Address - Fax:
Practice Address - Street 1:5807 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97478-6961
Practice Address - Country:US
Practice Address - Phone:541-726-8426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0015909183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2586028OtherWALGREENS