Provider Demographics
NPI:1336412253
Name:ELY, AMY (CPHT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:ELY
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2438 SW EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-9159
Mailing Address - Country:US
Mailing Address - Phone:503-440-6635
Mailing Address - Fax:
Practice Address - Street 1:1727 SW ODEM MEDO RD
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756
Practice Address - Country:US
Practice Address - Phone:541-923-7223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-23
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORCPT-0002679OtherSTATE PHARMACIST LICENSE