Healthcare Provider Details

I. General information

NPI: 1154775864
Provider Name (Legal Business Name): SIRUM CHARITABLE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2016
Last Update Date: 04/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

334 SE 5TH AVE STE B
HILLSBORO OR
97123-4107
US

IV. Provider business mailing address

150 ALMA ST APT 116
MENLO PARK CA
94025-3748
US

V. Phone/Fax

Practice location:
  • Phone: 503-648-0782
  • Fax: 844-238-3420
Mailing address:
  • Phone: 650-488-7434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberCP-0000014
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: GEORGE WANG
Title or Position: CO-FOUNDER & DIRECTOR
Credential:
Phone: 650-488-7434