Provider Demographics
NPI:1740776319
Name:GOSTANIAN, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:GOSTANIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 NW WITHAM HILL DR APT 123
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-1648
Mailing Address - Country:US
Mailing Address - Phone:559-280-4063
Mailing Address - Fax:
Practice Address - Street 1:3862 RIVER RD N
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4866
Practice Address - Country:US
Practice Address - Phone:503-371-6717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-07
Last Update Date:2018-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPI-0012993333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy