Provider Demographics
NPI:1780201426
Name:CRISWELL, TIM RICHARD (CPHT)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:RICHARD
Last Name:CRISWELL
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:979 NE HOOD AVE
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-5616
Mailing Address - Country:US
Mailing Address - Phone:503-575-8185
Mailing Address - Fax:
Practice Address - Street 1:600 NE 8TH ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7317
Practice Address - Country:US
Practice Address - Phone:503-988-5154
Practice Address - Fax:503-988-5509
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORCPT-0001684183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician