Provider Demographics
NPI:1497170849
Name:LEGACY MERIDAN PARK HOSPITAL
Entity Type:Organization
Organization Name:LEGACY MERIDAN PARK HOSPITAL
Other - Org Name:MERIDIAN PARK MEDICAL CENTER COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHCY SRVCS MGR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SIEG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:503-692-2665
Mailing Address - Street 1:19300 SW 65TH AVE
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-7706
Mailing Address - Country:US
Mailing Address - Phone:503-692-2454
Mailing Address - Fax:503-692-7437
Practice Address - Street 1:19300 SW 65TH AVE
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7706
Practice Address - Country:US
Practice Address - Phone:503-692-7470
Practice Address - Fax:503-692-7437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-21
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP-00008643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2144384OtherPK