Healthcare Provider Details

I. General information

NPI: 1134926520
Provider Name (Legal Business Name): TRACI LYNN PETERS PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TRACI LYNN HARRIS PHARMD

II. Dates (important events)

Enumeration Date: 02/25/2025
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24988 SE STARK ST STE 320
GRESHAM OR
97030-8325
US

IV. Provider business mailing address

11531 SE ROSS RD
HAPPY VALLEY OR
97086-6440
US

V. Phone/Fax

Practice location:
  • Phone: 503-674-1229
  • Fax: 503-674-1169
Mailing address:
  • Phone: 503-679-4505
  • Fax: 503-674-1169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberIND-908853
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRPH-0009623
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: