Provider Demographics
NPI:1578856969
Name:TAIT, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:TAIT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13130 SE 84TH AVE
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-9733
Mailing Address - Country:US
Mailing Address - Phone:503-794-5520
Mailing Address - Fax:503-794-5528
Practice Address - Street 1:25900 SW HEATHER PL
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-5785
Practice Address - Country:US
Practice Address - Phone:503-825-4005
Practice Address - Fax:503-825-4023
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0009311183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist