Provider Demographics
NPI:1497029417
Name:PHELPS, KATHY DAWN (RPH)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:DAWN
Last Name:PHELPS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 GRANTS PASS PKWY
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-2333
Mailing Address - Country:US
Mailing Address - Phone:541-474-7234
Mailing Address - Fax:
Practice Address - Street 1:1101 GRANTS PASS PKWY
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-2333
Practice Address - Country:US
Practice Address - Phone:541-474-7234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-08
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0011052183500000X
OR110521835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0011052OtherPHARMACY LICENSE