MEDICARE: MULTNOMAH COUNTY

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	3336C0002X	Clinic Pharmacy
2	3336C0003X	Community/Retail Pharmacy
3	333600000X	Pharmacy	RP-0000961-CS	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2078364	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528073319
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MULTNOMAH COUNTY

Provider Business Mailing Address
First Line	:	619 NW 6TH AVE FL 7
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97209-3964
Country	:	US
Telephone Number	:	503-988-3634
Fax Number	:	503-988-4345

Provider Business Practice Location Address
First Line	:	5329 NE MARTIN L KING FL JRBLVD2
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97211-3237
Country	:	US
Telephone Number	:	503-988-3634
Fax Number	:	503-988-4345

Authorized Official
Title or Position	:	PHARMACY DIRECTOR
Name	:	MICHELE KODER
Credential	:
Telephone Number	:	503-988-7278

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	11/08/2019

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Directions to “MULTNOMAH COUNTY ” Practice Location

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