Provider Demographics
NPI:1821535840
Name:BALYSHEV, MARK (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BALYSHEV
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 1:16300 SE EVELYN ST, CLACKAMAS, OR 97015
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97015
Mailing Address - Country:US
Mailing Address - Phone:503-305-9700
Mailing Address - Fax:
Practice Address - Street 1:2602 SE BELLA VISTA RD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-7616
Practice Address - Country:US
Practice Address - Phone:503-810-3786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-28
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0015760183500000X, 1835P0018X
WA60671067183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist