Provider Demographics
NPI:1912298522
Name:ROSALES, AVALYN CAPISTRANO (RPH)
Entity Type:Individual
Prefix:MISS
First Name:AVALYN
Middle Name:CAPISTRANO
Last Name:ROSALES
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11930 SE DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-1037
Mailing Address - Country:US
Mailing Address - Phone:503-761-6640
Mailing Address - Fax:503-760-9219
Practice Address - Street 1:11930 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-1037
Practice Address - Country:US
Practice Address - Phone:503-761-6640
Practice Address - Fax:503-760-9219
Is Sole Proprietor?:No
Enumeration Date:2011-04-29
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0010570183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORRPH-0010570OtherPHARMACY LICENSE