Healthcare Provider Details

I. General information

NPI: 1073903563
Provider Name (Legal Business Name): JOVIN V PANTHAPATTU PHARM.D. BCACP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2015
Last Update Date: 04/16/2020
Certification Date: 04/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

178 SW 2ND AVE
CANBY OR
97013-4152
US

IV. Provider business mailing address

7320 SW HUNZIKER RD STE 300
PORTLAND OR
97223-2302
US

V. Phone/Fax

Practice location:
  • Phone: 503-416-4547
  • Fax: 503-416-4553
Mailing address:
  • Phone: 35-941-3033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberRPH-0016544
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRPH-0016544-P
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: