Provider Demographics
NPI:1376944058
Name:PITLUCK, GEOFFREY (RPH)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:
Last Name:PITLUCK
Suffix:
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 1:699 WALLACE RD NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-3834
Mailing Address - Country:US
Mailing Address - Phone:503-428-5073
Mailing Address - Fax:
Practice Address - Street 1:699 WALLACE RD NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-3834
Practice Address - Country:US
Practice Address - Phone:503-428-5073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-12
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-10193183500000X
IN26020298A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist