Healthcare Provider Details

I. General information

NPI: 1891052700
Provider Name (Legal Business Name): AMANDA RUTH NORMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2012
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2497 SE BURNSIDE RD
GRESHAM OR
97080-1246
US

IV. Provider business mailing address

19864 SOPHIA CT
OREGON CITY OR
97045-7569
US

V. Phone/Fax

Practice location:
  • Phone: 503-669-4233
  • Fax: 503-669-4238
Mailing address:
  • Phone: 971-230-4108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH 60546107
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH - 0014810
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRPH-0014810
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: