Healthcare Provider Details

I. General information

NPI: 1710746458
Provider Name (Legal Business Name): PNW PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2024
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 NE 7TH ST
GRESHAM OR
97030-5604
US

IV. Provider business mailing address

400 NE 7TH ST
GRESHAM OR
97030-5604
US

V. Phone/Fax

Practice location:
  • Phone: 503-573-3278
  • Fax: 503-573-3270
Mailing address:
  • Phone: 503-573-3278
  • Fax: 503-573-3270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DAN BIEURANCE
Title or Position: OWNER
Credential:
Phone: 612-986-7827