MEDICARE: MR. CORSON COLLET PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	7102	OR

General Provider Information

NPI Number	:	1285884478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CORSON COLLET PHARMD

Provider Business Mailing Address
First Line	:	10180 S.E. SUNNYSIDE ROAD
Second Line	:	INPATIENT PHARMACY KAISER SUNNYSIDE MC
City	:	CLACKAMAS
State	:	OR
Zip	:	97015-9303
Country	:	US
Telephone Number	:	503-571-4665
Fax Number	:

Provider Business Practice Location Address
First Line	:	10180 S.E. SUNNYSIDE ROAD
Second Line	:	INPATIENT PHARMACY KAISER SUNNYSIDE MC
City	:	CLACKAMAS
State	:	OR
Zip	:	97015-9303
Country	:	US
Telephone Number	:	503-571-4665
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/24/2008
Last Update Date	:	09/24/2008

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