Healthcare Provider Details

I. General information

NPI: 1235559881
Provider Name (Legal Business Name): MR. BRAD CRAIG BOEHME
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2014
Last Update Date: 04/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9775 SW GEMINI DR STE 1
BEAVERTON OR
97008-7148
US

IV. Provider business mailing address

9775 SW GEMINI DR STE 1
BEAVERTON OR
97008-7148
US

V. Phone/Fax

Practice location:
  • Phone: 866-202-4014
  • Fax:
Mailing address:
  • Phone: 866-202-4014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0008601
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number47988
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number13142
License Number StateNE
# 4
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS015044
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: