Provider Demographics
NPI:1902416175
Name:PEACEHEALTH NETWORKS ON DEMAND, LLC
Entity Type:Organization
Organization Name:PEACEHEALTH NETWORKS ON DEMAND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MALLORY
Authorized Official - Middle Name:ALYSE
Authorized Official - Last Name:KEMPTON-HEIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:503-941-3807
Mailing Address - Street 1:1455 NW IRVING ST STE 600
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2277
Mailing Address - Country:US
Mailing Address - Phone:503-941-3807
Mailing Address - Fax:503-941-3809
Practice Address - Street 1:8179 N LOMBARD ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-3130
Practice Address - Country:US
Practice Address - Phone:503-941-3807
Practice Address - Fax:503-941-3809
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEACEHEALTH NETWORKS ON DEMAND, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000054-CSOtherSUPERVISING PHYSICIAN DISPENSING OUTLET