Provider Demographics
NPI:1780968578
Name:FORTNER, JEFFERY DALE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:DALE
Last Name:FORTNER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 SE 8TH AVE
Mailing Address - Street 2:SUITE 451
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4218
Mailing Address - Country:US
Mailing Address - Phone:503-352-7269
Mailing Address - Fax:503-352-7270
Practice Address - Street 1:1125 NE 99TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-9428
Practice Address - Country:US
Practice Address - Phone:503-254-7383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0010486183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist