Provider Demographics
NPI:1669772968
Name:BRYANT, PETE (STUDENT)
Entity type:Individual
Prefix:
First Name:PETE
Middle Name:
Last Name:BRYANT
Suffix:
Gender:M
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 SATARA CT NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-2811
Mailing Address - Country:US
Mailing Address - Phone:206-229-1085
Mailing Address - Fax:
Practice Address - Street 1:530 NW 27TH ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-5223
Practice Address - Country:US
Practice Address - Phone:541-766-6835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPI-0010074183500000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No183500000XPharmacy Service ProvidersPharmacist