Provider Demographics
NPI:1255645271
Name:ROCKWOOD HEALTH CLINIC PHARMACY
Entity type:Organization
Organization Name:ROCKWOOD HEALTH CLINIC PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:KODER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-988-7278
Mailing Address - Street 1:619 NW 6TH AVE FL 7
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3964
Mailing Address - Country:US
Mailing Address - Phone:503-988-3353
Mailing Address - Fax:503-988-4345
Practice Address - Street 1:2020 SE 182ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-5692
Practice Address - Country:US
Practice Address - Phone:503-988-3353
Practice Address - Fax:503-988-4345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-02
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X
ORRP-0002610-CS3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3843869OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OR500624853Medicaid