Provider Demographics
NPI:1972078889
Name:ALI, ABDIGANI M
Entity Type:Individual
Prefix:
First Name:ABDIGANI
Middle Name:M
Last Name:ALI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16300 SE EVELYN ST
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-9515
Mailing Address - Country:US
Mailing Address - Phone:503-350-2086
Mailing Address - Fax:
Practice Address - Street 1:13485 NW CORNELL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-5819
Practice Address - Country:US
Practice Address - Phone:503-350-2086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-06
Last Update Date:2018-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0016910183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist