Provider Demographics
NPI:1720493968
Name:MEDICATION MANAGEMENT PROGRAM
Entity Type:Organization
Organization Name:MEDICATION MANAGEMENT PROGRAM
Other - Org Name:MEDICATION MANAGEMENT PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-261-7980
Mailing Address - Street 1:5717 NE 138TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-3409
Mailing Address - Country:US
Mailing Address - Phone:503-261-7541
Mailing Address - Fax:503-261-2048
Practice Address - Street 1:5717 NE 138TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-3409
Practice Address - Country:US
Practice Address - Phone:503-261-7541
Practice Address - Fax:503-261-2048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-26
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA000586573336C0002X
OR21313336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR136668Medicaid
WA6019392Medicaid
2146486OtherPK