Healthcare Provider Details

I. General information

NPI: 1790058428
Provider Name (Legal Business Name): PATRICIA KAY JOLLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2012
Last Update Date: 02/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 CAMPBELL ST
BAKER CITY OR
97814-2212
US

IV. Provider business mailing address

700 CAMPBELL ST
BAKER CITY OR
97814-2212
US

V. Phone/Fax

Practice location:
  • Phone: 541-523-0607
  • Fax: 541-523-0589
Mailing address:
  • Phone: 541-523-0607
  • Fax: 541-523-0589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH 00019693
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH-0006801
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: