Healthcare Provider Details

I. General information

NPI: 1760762801
Provider Name (Legal Business Name): MARIA VINCIC PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2011
Last Update Date: 08/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 NE HALSEY ST BLDG 2 PROVIDENCE MEDICAL GROUP, SUITE 490
PORTLAND OR
97213-1545
US

IV. Provider business mailing address

19000 NW EVERGREEN PKWY APT 33
HILLSBORO OR
97124-7005
US

V. Phone/Fax

Practice location:
  • Phone: 503-893-6906
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH60240163
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRPH-0013002
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: