Provider Demographics
NPI:1437480316
Name:MICKELSON, RYAN AMOS (PHARMD, BCPS)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:AMOS
Last Name:MICKELSON
Suffix:
Gender:M
Credentials:PHARMD, BCPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 SW HOOKER ST
Mailing Address - Street 2:APT 1
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-4774
Mailing Address - Country:US
Mailing Address - Phone:608-212-9204
Mailing Address - Fax:
Practice Address - Street 1:3750 CHEMAWA RD NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1119
Practice Address - Country:US
Practice Address - Phone:503-304-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-16
Last Update Date:2010-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15475-040183500000X
ORRPH-0011121183500000X
ORBCPS 3080099531835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy