Provider Demographics
NPI:1639651490
Name:BEAVERTON PHARMACY INC
Entity Type:Organization
Organization Name:BEAVERTON PHARMACY INC
Other - Org Name:BEAVERTON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:IRBY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:503-644-2101
Mailing Address - Street 1:12250 SW CANYON RD
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2116
Mailing Address - Country:US
Mailing Address - Phone:503-644-2101
Mailing Address - Fax:
Practice Address - Street 1:12250 SW CANYON RD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2116
Practice Address - Country:US
Practice Address - Phone:503-644-2101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEAVERTON PHARMACY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP-0000129-CS3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy