Provider Demographics
NPI:1689040727
Name:FRY, MADELINE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:FRY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 SW 5TH AVE
Mailing Address - Street 2:SUITE 900
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-1753
Mailing Address - Country:US
Mailing Address - Phone:503-416-5819
Mailing Address - Fax:
Practice Address - Street 1:1425 BEAVERCREEK RD
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-4076
Practice Address - Country:US
Practice Address - Phone:503-655-8471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0014191183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist