Provider Demographics
NPI:1962015230
Name:AMMON, ELIZA (RPH)
Entity Type:Individual
Prefix:
First Name:ELIZA
Middle Name:
Last Name:AMMON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3092 FIR OAKS DR SW
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-3552
Mailing Address - Country:US
Mailing Address - Phone:408-480-1494
Mailing Address - Fax:
Practice Address - Street 1:1333 CLAY ST SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-6868
Practice Address - Country:US
Practice Address - Phone:541-924-9598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0018003183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist