Provider Demographics
NPI:1659991586
Name:MEDLIN, BILLY DAKOTA (CPT)
Entity Type:Individual
Prefix:
First Name:BILLY
Middle Name:DAKOTA
Last Name:MEDLIN
Suffix:
Gender:M
Credentials:CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N PACIFIC HWY APT 107
Mailing Address - Street 2:
Mailing Address - City:TALENT
Mailing Address - State:OR
Mailing Address - Zip Code:97540-9505
Mailing Address - Country:US
Mailing Address - Phone:409-750-1258
Mailing Address - Fax:
Practice Address - Street 1:53 N 2ND ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-1889
Practice Address - Country:US
Practice Address - Phone:541-428-3366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORCPT-0010850183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician