Healthcare Provider Details

I. General information

NPI: 1609308071
Provider Name (Legal Business Name): ALEXIS PROTEAU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 NW GARDEN VALLEY BLVD
ROSEBURG OR
97471-6523
US

IV. Provider business mailing address

913 NW GARDEN VALLEY BLVD
ROSEBURG OR
97471-6523
US

V. Phone/Fax

Practice location:
  • Phone: 541-440-1000
  • Fax: 541-440-1000
Mailing address:
  • Phone: 541-440-1000
  • Fax: 541-440-1000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH-0019132
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberT-0021549
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: