Provider Demographics
NPI:1396165361
Name:TADINA, JUSTIN (RPH)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:TADINA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12080 SW MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6218
Mailing Address - Country:US
Mailing Address - Phone:503-620-9322
Mailing Address - Fax:
Practice Address - Street 1:12080 SW MAIN ST
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6218
Practice Address - Country:US
Practice Address - Phone:503-620-9322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-17
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0013973183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist