Healthcare Provider Details

I. General information

NPI: 1134131212
Provider Name (Legal Business Name): TERRI LEE FAGAN RPH, CGP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4560 SE INTERNATIONAL WAY SUITE 101
MILWAUKIE OR
97222-4628
US

IV. Provider business mailing address

1834 SE 47TH AVE
PORTLAND OR
97215-3208
US

V. Phone/Fax

Practice location:
  • Phone: 971-206-5205
  • Fax:
Mailing address:
  • Phone: 503-243-5192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0008961
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: