Provider Demographics
NPI:1639302201
Name:VAN VALKENBURG, LECIA MARION
Entity Type:Individual
Prefix:
First Name:LECIA
Middle Name:MARION
Last Name:VAN VALKENBURG
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 1:12240 SW SCHOLLS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-3354
Mailing Address - Country:US
Mailing Address - Phone:503-590-7346
Mailing Address - Fax:503-590-2584
Practice Address - Street 1:12240 SW SCHOLLS FERRY RD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-3354
Practice Address - Country:US
Practice Address - Phone:503-590-7346
Practice Address - Fax:503-590-2584
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR183500000X183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist