Healthcare Provider Details

I. General information

NPI: 1710972500
Provider Name (Legal Business Name): HENRY TANG R.PH., AE-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2005
Last Update Date: 03/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 971-206-5100
  • Fax: 503-652-0383
Mailing address:
  • Phone: 971-206-5100
  • Fax: 503-652-0383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8514
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number17707
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number60028510
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number8514
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: