Provider Demographics
NPI:1881996189
Name:ISSE, FRED P (RPH)
Entity type:Individual
Prefix:MR
First Name:FRED
Middle Name:P
Last Name:ISSE
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 1:10254 SE TERRA LINDA CT
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-6890
Mailing Address - Country:US
Mailing Address - Phone:503-449-3733
Mailing Address - Fax:
Practice Address - Street 1:10254 SE TERRA LINDA CT
Practice Address - Street 2:
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-6890
Practice Address - Country:US
Practice Address - Phone:503-777-5679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-19
Last Update Date:2016-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR72411835P0018X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR7241OtherOREGON BOARD OF PHARMACY