Healthcare Provider Details

I. General information

NPI: 1255949285
Provider Name (Legal Business Name): CHARLES WHITNEY BODREAU PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2020
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20233 SW JAY ST
ALOHA OR
97003-8137
US

IV. Provider business mailing address

20233 SW JAY ST
ALOHA OR
97003-8137
US

V. Phone/Fax

Practice location:
  • Phone: 971-221-8200
  • Fax:
Mailing address:
  • Phone: 971-221-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0016852
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number0016852
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number021408
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: