Provider Demographics
NPI:1659755593
Name:PORTLAND PROFESSIONAL PHARMACY, LLC
Entity Type:Organization
Organization Name:PORTLAND PROFESSIONAL PHARMACY, LLC
Other - Org Name:PORTLAND PROFESSIONAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HODGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-203-4797
Mailing Address - Street 1:11717 NE GLISAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-2141
Mailing Address - Country:US
Mailing Address - Phone:702-203-4797
Mailing Address - Fax:
Practice Address - Street 1:11717 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-2141
Practice Address - Country:US
Practice Address - Phone:971-200-8324
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-09
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP-0003101-CS3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy