Provider Demographics
NPI:1922330828
Name:PROVIDENCE HEALTH & SERVICES OREGON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES OREGON
Other - Org Name:PROVIDENCE BRIDGEPORT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, FINANCIAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-215-8584
Mailing Address - Street 1:18040 SW LOWER BOONES FERRY RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7258
Mailing Address - Country:US
Mailing Address - Phone:503-216-0625
Mailing Address - Fax:503-216-0630
Practice Address - Street 1:18040 SW LOWER BOONES FERRY RD STE 104
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7259
Practice Address - Country:US
Practice Address - Phone:503-216-0625
Practice Address - Fax:503-216-0630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-03
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP-0002571-CS3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3843768OtherNCPDP PROVIDER IDENTIFICATION NUMBER