Provider Demographics
NPI:1124610209
Name:LANDREVILLE, AUSTIN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:AUSTIN
Middle Name:
Last Name:LANDREVILLE
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 1:1401 N 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:STAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97383-1311
Mailing Address - Country:US
Mailing Address - Phone:503-769-9223
Mailing Address - Fax:503-769-2479
Practice Address - Street 1:1401 N 10TH AVE
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383-1311
Practice Address - Country:US
Practice Address - Phone:503-769-9223
Practice Address - Fax:503-769-2479
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0018018183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist