Provider Demographics
NPI:1457901498
Name:PHARMACY DOT COM 82ND
Entity Type:Organization
Organization Name:PHARMACY DOT COM 82ND
Other - Org Name:PHARMACY DOT COM 82ND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JASMINE
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-450-9194
Mailing Address - Street 1:5253 SE 82ND AVE UNIT 27
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-4885
Mailing Address - Country:US
Mailing Address - Phone:503-477-8453
Mailing Address - Fax:503-477-8416
Practice Address - Street 1:5253 SE 82ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-4862
Practice Address - Country:US
Practice Address - Phone:503-477-8453
Practice Address - Fax:503-477-8416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-11
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500772894Medicaid