Provider Demographics
NPI:1407475577
Name:BAKKEGARD, ROBERT (RPH)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:BAKKEGARD
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:PO BOX 1097
Mailing Address - Street 2:
Mailing Address - City:CANYONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97417-1097
Mailing Address - Country:US
Mailing Address - Phone:503-871-1297
Mailing Address - Fax:
Practice Address - Street 1:314 S MAIN STREET
Practice Address - Street 2:
Practice Address - City:CANYONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97417
Practice Address - Country:US
Practice Address - Phone:541-839-4452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0006386183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORRPH-0006386OtherOREGON BOARD OF PHARMACY LICENSE