Provider Demographics
NPI:1184997801
Name:FLAKE, JANEEN VI (RPH)
Entity type:Individual
Prefix:MRS
First Name:JANEEN
Middle Name:VI
Last Name:FLAKE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13256 SW HILLSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5600
Mailing Address - Country:US
Mailing Address - Phone:503-502-4649
Mailing Address - Fax:
Practice Address - Street 1:3225 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-1912
Practice Address - Country:US
Practice Address - Phone:503-357-2034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0007788183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0007788OtherSTATE PHARMACIST LICENSE