Provider Demographics
NPI:1265768774
Name:JMSP LLC
Entity type:Organization
Organization Name:JMSP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-203-4797
Mailing Address - Street 1:10000 SE MAIN ST
Mailing Address - Street 2:STE 118
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2448
Mailing Address - Country:US
Mailing Address - Phone:503-255-2546
Mailing Address - Fax:503-255-3893
Practice Address - Street 1:10000 SE MAIN ST
Practice Address - Street 2:STE 118
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2448
Practice Address - Country:US
Practice Address - Phone:503-255-2546
Practice Address - Fax:503-255-3893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-19
Last Update Date:2019-06-14
Deactivation Date:2019-02-25
Deactivation Code:
Reactivation Date:2019-06-14
Provider Licenses
StateLicense IDTaxonomies
333600000X
ORRP0000689CS3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2122445OtherPK