Healthcare Provider Details

I. General information

NPI: 1265768774
Provider Name (Legal Business Name): JMSP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2009
Last Update Date: 06/14/2019
Certification Date:
Deactivation Date: 02/25/2019
Reactivation Date: 06/14/2019

III. Provider practice location address

10000 SE MAIN ST STE 118
PORTLAND OR
97216-2448
US

IV. Provider business mailing address

10000 SE MAIN ST STE 118
PORTLAND OR
97216-2448
US

V. Phone/Fax

Practice location:
  • Phone: 503-255-2546
  • Fax: 503-255-3893
Mailing address:
  • Phone: 503-255-2546
  • Fax: 503-255-3893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW PETERS
Title or Position: MANAGER
Credential:
Phone: 702-203-4797