Provider Demographics
NPI:1477151975
Name:SMITH, MISTY (PHARMD)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:SMITH
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 1:5218 PACIFIC WAY
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-9654
Mailing Address - Country:US
Mailing Address - Phone:360-747-3880
Mailing Address - Fax:
Practice Address - Street 1:444 SE STEPHENS ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3136
Practice Address - Country:US
Practice Address - Phone:541-672-4896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-00018127183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORRPH-0018127OtherPHARMACIST LICENSE