Provider Demographics
NPI:1255885463
Name:CHUKWULETA, PAMELA
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:CHUKWULETA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 SW 5TH AVE
Mailing Address - Street 2:SUITE 900
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-1753
Mailing Address - Country:US
Mailing Address - Phone:503-416-5864
Mailing Address - Fax:
Practice Address - Street 1:315 SW 5TH AVE
Practice Address - Street 2:SUITE 900
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-1753
Practice Address - Country:US
Practice Address - Phone:503-416-5864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0015422183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist