Provider Demographics
NPI:1669450201
Name:WIPPERT, REBECCA PHOEBE
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:PHOEBE
Last Name:WIPPERT
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:REBECCA
Other - Middle Name:PHOEBE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1949 STEIWER RD SE
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:OR
Mailing Address - Zip Code:97352-9802
Mailing Address - Country:US
Mailing Address - Phone:503-589-4357
Mailing Address - Fax:
Practice Address - Street 1:3750 CHEMAWA RD NE
Practice Address - Street 2:CHEMAWA INDIAN HEALTH CENTER
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1111
Practice Address - Country:US
Practice Address - Phone:503-304-7603
Practice Address - Fax:503-304-7677
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT0006986183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician