Healthcare Provider Details

I. General information

NPI: 1427274927
Provider Name (Legal Business Name): PACIFIC COAST MEDICAL SUPPLY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2158 EXCHANGE ST STE 106
ASTORIA OR
97103-3316
US

IV. Provider business mailing address

PO BOX 634
ASTORIA OR
97103-0634
US

V. Phone/Fax

Practice location:
  • Phone: 503-338-0349
  • Fax: 503-338-6998
Mailing address:
  • Phone: 503-338-0349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License NumberNPC-0001961
License Number StateOR
# 4
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier9046947
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer
# 2
Identifier500600821
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: NORMAN D STUTZNEGGER
Title or Position: PRESIDENT
Credential:
Phone: 503-338-0349