Provider Demographics
NPI:1962012955
Name:PEACEHEALTH NETWORKS ON DEMAND, LLC
Entity Type:Organization
Organization Name:PEACEHEALTH NETWORKS ON DEMAND, LLC
Other - Org Name:ZOOMCARE-LAKE OSWEGO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
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:503-684-8252
Mailing Address - Street 1:11958 SW GARDEN PL
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8248
Mailing Address - Country:US
Mailing Address - Phone:503-684-8252
Mailing Address - Fax:866-859-8195
Practice Address - Street 1:111 A AVE
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-3116
Practice Address - Country:US
Practice Address - Phone:503-684-8252
Practice Address - Fax:866-859-8195
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEACEHEALTH NETWORKS ON DEMAND, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-08-04
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000063OtherDISPENSING PRACTITIONER DRUG OUTLET