Provider Demographics
NPI:1669841482
Name:NAZARETYAN, YAKOV
Entity Type:Individual
Prefix:
First Name:YAKOV
Middle Name:
Last Name:NAZARETYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30299 SW BOONES FERRY RD
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-7844
Mailing Address - Country:US
Mailing Address - Phone:503-682-4435
Mailing Address - Fax:
Practice Address - Street 1:30299 SW BOONES FERRY RD
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-7844
Practice Address - Country:US
Practice Address - Phone:503-682-4435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-22
Last Update Date:2016-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0013290183500000X
ORRPH-00132901835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist