Provider Demographics
NPI:1871265207
Name:BODINE, COLE MICHAEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:COLE
Middle Name:MICHAEL
Last Name:BODINE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5717 NE 138TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-3499
Mailing Address - Country:US
Mailing Address - Phone:503-821-3814
Mailing Address - Fax:
Practice Address - Street 1:5717 NE 138TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-3499
Practice Address - Country:US
Practice Address - Phone:503-821-3814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-00185091835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORRPH-0018509OtherPHARMACIST LICENSE