Provider Demographics
NPI:1972281988
Name:PEACEHEALTH
Entity Type:Organization
Organization Name:PEACEHEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENNAN
Authorized Official - Middle Name:DUANE
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:541-222-5800
Mailing Address - Street 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3333 RIVERBEND DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-8800
Practice Address - Country:US
Practice Address - Phone:541-222-5800
Practice Address - Fax:541-431-9149
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEACEHEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy