Healthcare Provider Details

I. General information

NPI: 1760147201
Provider Name (Legal Business Name): BRETT GILL PHARMACY INTERN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2021
Last Update Date: 10/31/2021
Certification Date: 10/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NW 27TH ST
CORVALLIS OR
97330-5223
US

IV. Provider business mailing address

530 NW 27TH ST
CORVALLIS OR
97330-5223
US

V. Phone/Fax

Practice location:
  • Phone: 541-766-6835
  • Fax:
Mailing address:
  • Phone: 541-766-6835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberPI0013314
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: