Healthcare Provider Details

I. General information

NPI: 1992061048
Provider Name (Legal Business Name): RUSSELL A WENDT RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2012
Last Update Date: 05/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2497 NE ROBERTS AVE
GRESHAM OR
97080
US

IV. Provider business mailing address

2497 NE ROBERTS AVE
GRESHAM OR
97080
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number7549
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRPH0007549
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: