Healthcare Provider Details

I. General information

NPI: 1588741458
Provider Name (Legal Business Name): ASSURED PHARMACY GRESHAM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 03/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 NW COUNSIL DR STE 115
GRESHAM OR
97030
US

IV. Provider business mailing address

5760 LEGACY DR STE. B3-518
PLANO TX
75024-7102
US

V. Phone/Fax

Practice location:
  • Phone: 971-223-0552
  • Fax: 503-492-2148
Mailing address:
  • Phone: 972-668-7394
  • Fax: 866-232-1680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberRP0002366
License Number StateOR

VIII. Authorized Official

Name: JULIETTE JOHNSON
Title or Position: ACCOUNTING ANALYST
Credential:
Phone: 972-668-7394