Provider Demographics
NPI:1598831133
Name:PROVIDENCE HEALTH & SERVICES OREGON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES OREGON
Other - Org Name:PROVIDENCE MILWAUKIE HOSP PHCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTHONY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:503-513-8381
Mailing Address - Street 1:10150 SE 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-6516
Mailing Address - Country:US
Mailing Address - Phone:503-513-8331
Mailing Address - Fax:503-513-8324
Practice Address - Street 1:10150 SE 32ND AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-6516
Practice Address - Country:US
Practice Address - Phone:503-513-8331
Practice Address - Fax:503-513-8324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP0000827CS333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR175620Medicaid
3802837OtherNCPDP PROVIDER IDENTIFICATION NUMBER