Provider Demographics
NPI:1972053148
Name:BROCK, CAMERON JOHN (PHARMD)
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:JOHN
Last Name:BROCK
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 1:14716 SW BEARD RD APT 309
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-6200
Mailing Address - Country:US
Mailing Address - Phone:602-821-5434
Mailing Address - Fax:
Practice Address - Street 1:1255 NE 48TH AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-5008
Practice Address - Country:US
Practice Address - Phone:503-681-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0015475183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist