Provider Demographics
NPI:1972916492
Name:PODOLL, LOREN
Entity Type:Individual
Prefix:
First Name:LOREN
Middle Name:
Last Name:PODOLL
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 1:1920 MADRAS ST SE
Mailing Address - Street 2:APT 2028
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-2082
Mailing Address - Country:US
Mailing Address - Phone:701-212-6805
Mailing Address - Fax:
Practice Address - Street 1:2000 CRATER LAKE HWY
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-4161
Practice Address - Country:US
Practice Address - Phone:541-779-5110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0013627183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist