Provider Demographics
NPI:1265896542
Name:CARROLL, MEGAN MOLLY (PHARMD)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:MOLLY
Last Name:CARROLL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 SW BERTHA BLVD APT 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-2078
Mailing Address - Country:US
Mailing Address - Phone:541-990-6727
Mailing Address - Fax:
Practice Address - Street 1:1015 SW BERTHA BLVD APT 2
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-2078
Practice Address - Country:US
Practice Address - Phone:541-990-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPI-0011511390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORPI-0011511OtherPHARMACY LICENSE