Provider Demographics
NPI:1598216475
Name:FRED MEYER
Entity Type:Organization
Organization Name:FRED MEYER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-585-1193
Mailing Address - Street 1:2200 BASELINE ST
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:OR
Mailing Address - Zip Code:97113-8618
Mailing Address - Country:US
Mailing Address - Phone:503-359-3103
Mailing Address - Fax:503-359-3341
Practice Address - Street 1:2200 BASELINE ST
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:OR
Practice Address - Zip Code:97113-8618
Practice Address - Country:US
Practice Address - Phone:503-359-3103
Practice Address - Fax:503-359-3341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0015554261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center