Healthcare Provider Details

I. General information

NPI: 1922324896
Provider Name (Legal Business Name): JEAN EDSON SIMON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: EDSON SIMON BSRPH

II. Dates (important events)

Enumeration Date: 04/15/2010
Last Update Date: 04/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 NE BURNSIDE RD
GRESHAM OR
97030-7949
US

IV. Provider business mailing address

13888 SE 119TH DR
CLACKAMAS OR
97015-6636
US

V. Phone/Fax

Practice location:
  • Phone: 503-674-8482
  • Fax:
Mailing address:
  • Phone: 503-698-6336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0010145
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: