Provider Demographics
NPI:1497354880
Name:MIRACLE, JUSTIN TYLER
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:TYLER
Last Name:MIRACLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 NW KINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-5620
Mailing Address - Country:US
Mailing Address - Phone:503-877-4430
Mailing Address - Fax:
Practice Address - Street 1:777 NW KINGS BLVD
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-5620
Practice Address - Country:US
Practice Address - Phone:541-754-5583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-18
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPI-0013024390200000X
ORRPH0018483183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program