Healthcare Provider Details

I. General information

NPI: 1154328664
Provider Name (Legal Business Name): EDYTH ADELE WILLARD PHARM D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 10/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4531 SE BELMONT ST SUITE 100
PORTLAND OR
97215-1675
US

IV. Provider business mailing address

4531 SE BELMONT ST SUITE 100
PORTLAND OR
97215-1675
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-8774
  • Fax:
Mailing address:
  • Phone: 503-215-8774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License Number11799
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number5654
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number5654
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: