Healthcare Provider Details

I. General information

NPI: 1053628503
Provider Name (Legal Business Name): KENNETH ANDREW ERNST RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2010
Last Update Date: 09/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17850 LOWER BOONES FERRY RD
LAKE OSWEGO OR
97035-5228
US

IV. Provider business mailing address

97 KINGSGATE RD APT. E12
LAKE OSWEGO OR
97035-2371
US

V. Phone/Fax

Practice location:
  • Phone: 971-233-0113
  • Fax:
Mailing address:
  • Phone: 801-652-6661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH0012176
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: