Provider Demographics
NPI:1770676124
Name:PHARMACY EXPRESS OF PORTLAND INC
Entity Type:Organization
Organization Name:PHARMACY EXPRESS OF PORTLAND INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:BANDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-325-5600
Mailing Address - Street 1:105 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37148-1113
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 N BROADWAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148-1113
Practice Address - Country:US
Practice Address - Phone:615-325-5600
Practice Address - Fax:615-325-5636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3896333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4436526OtherOTHER ID NUMBER-COMMERCIAL NUMBER
4436526OtherOTHER ID NUMBER-COMMERCIAL NUMBER