Provider Demographics
NPI:1750654968
Name:DEFAZIO, ANTHONY F (RPH)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:F
Last Name:DEFAZIO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17108 SE POWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-1753
Mailing Address - Country:US
Mailing Address - Phone:503-667-5377
Mailing Address - Fax:503-666-9257
Practice Address - Street 1:17108 SE POWELL BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-1753
Practice Address - Country:US
Practice Address - Phone:503-667-5377
Practice Address - Fax:503-666-9257
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0005733183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORRPH-0005733OtherSTATE PHARMACIST LICENSE