Provider Demographics
NPI:1770994964
Name:KOSTECHKA, ANDY WALTER (RPH)
Entity type:Individual
Prefix:MR
First Name:ANDY
Middle Name:WALTER
Last Name:KOSTECHKA
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 1:16100 SW 72ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7745
Mailing Address - Country:US
Mailing Address - Phone:503-626-9436
Mailing Address - Fax:503-372-1792
Practice Address - Street 1:16100 SW 72ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97224-7745
Practice Address - Country:US
Practice Address - Phone:503-626-9436
Practice Address - Fax:503-372-1792
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-11
Last Update Date:2014-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6326183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist