Provider Demographics
NPI:1629320486
Name:BALLENSKY, AARON M
Entity Type:Individual
Prefix:
First Name:AARON
Middle Name:M
Last Name:BALLENSKY
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 1:390 N RIVER DR
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-8008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:390 N RIVER DR
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-8008
Practice Address - Country:US
Practice Address - Phone:541-743-5445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPI-0010645183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist