Provider Demographics
NPI:1417249137
Name:ILTIS, BETHANY JEAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:JEAN
Last Name:ILTIS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 B AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-3131
Mailing Address - Country:US
Mailing Address - Phone:503-697-0990
Mailing Address - Fax:503-697-8637
Practice Address - Street 1:90 B AVE
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-3131
Practice Address - Country:US
Practice Address - Phone:503-697-0990
Practice Address - Fax:503-697-8637
Is Sole Proprietor?:No
Enumeration Date:2011-05-13
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0011364183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist