Healthcare Provider Details

I. General information

NPI: 1912064478
Provider Name (Legal Business Name): MAPLE STREET CLINIC PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 MAPLE ST
FOREST GROVE OR
97116-1939
US

IV. Provider business mailing address

1825 MAPLE ST
FOREST GROVE OR
97116-1939
US

V. Phone/Fax

Practice location:
  • Phone: 503-357-7552
  • Fax: 503-359-5071
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberRP0000674CS
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER VORRATH
Title or Position: PRES
Credential: PHRM
Phone: 503-357-7552