Healthcare Provider Details

I. General information

NPI: 1174959555
Provider Name (Legal Business Name): FLETCHER K TANG PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2013
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 NE DIVISION ST
GRESHAM OR
97030-4271
US

IV. Provider business mailing address

1555 NE DIVISION STREET APARTMENT 311
GRESHAM OR
97030-3111
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-9476
  • Fax:
Mailing address:
  • Phone: 503-666-9476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH-0013731
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberORRPH0013731
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: