Healthcare Provider Details

I. General information

NPI: 1427604297
Provider Name (Legal Business Name): BRADEN JEFFREY ENFIELD RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2019
Last Update Date: 08/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 NW 9TH ST
CORVALLIS OR
97330-1484
US

IV. Provider business mailing address

2080 NW 9TH ST
CORVALLIS OR
97330-1484
US

V. Phone/Fax

Practice location:
  • Phone: 541-753-2226
  • Fax: 541-753-2559
Mailing address:
  • Phone: 541-753-2226
  • Fax: 541-753-2559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0017381
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: