Provider Demographics
NPI:1558373613
Name:PORTLAND COMPOUNDING PHARMACY LLC
Entity Type:Organization
Organization Name:PORTLAND COMPOUNDING PHARMACY LLC
Other - Org Name:LLOYD CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:NATALIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:503-281-4161
Mailing Address - Street 1:2606 NE BROADWAY ST STE B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1898
Mailing Address - Country:US
Mailing Address - Phone:503-281-4161
Mailing Address - Fax:503-281-1990
Practice Address - Street 1:2606 NE BROADWAY ST STE B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1898
Practice Address - Country:US
Practice Address - Phone:503-281-4161
Practice Address - Fax:503-281-1990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
ORRP-0000465-CS3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2134247OtherPK