Healthcare Provider Details

I. General information

NPI: 1063401198
Provider Name (Legal Business Name): GRESHAM PROFESSIONAL PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 10/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24076 SE STARK ST SUITE 100
GRESHAM OR
97030-3373
US

IV. Provider business mailing address

24076 SE STARK ST SUITE 100
GRESHAM OR
97030-3373
US

V. Phone/Fax

Practice location:
  • Phone: 503-491-0117
  • Fax: 503-489-2078
Mailing address:
  • Phone: 503-491-0117
  • Fax: 503-489-2078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8305
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number002102
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier299911
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier3815125
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerNABP/NCPDP #

VIII. Authorized Official

Name: DR. DAVID G MOLL
Title or Position: CEO
Credential: PHARMD
Phone: 503-491-0117