Healthcare Provider Details

I. General information

NPI: 1609896174
Provider Name (Legal Business Name): LEGACY GOOD SAMARITAN HOSPITAL AND MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 NW 22ND AVE SUITE 100
PORTLAND OR
97210-3057
US

IV. Provider business mailing address

1040 NW 22ND AVE SUITE 100
PORTLAND OR
97210
US

V. Phone/Fax

Practice location:
  • Phone: 503-413-8122
  • Fax:
Mailing address:
  • Phone: 503-413-4048
  • Fax: 503-413-4449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberRP-0001427-CS
License Number StateOR

VIII. Authorized Official

Name: SARAH JENSEN
Title or Position: VP FINANCE
Credential:
Phone: 503-415-5145