Healthcare Provider Details

I. General information

NPI: 1265760896
Provider Name (Legal Business Name): SHERI L SIDDALL RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2009
Last Update Date: 01/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 HAWTHORNE AVE SE
SALEM OR
97301-5090
US

IV. Provider business mailing address

1010 HAWTHORNE AVE SE
SALEM OR
97301-5090
US

V. Phone/Fax

Practice location:
  • Phone: 503-371-8739
  • Fax: 503-371-0294
Mailing address:
  • Phone: 503-371-8739
  • Fax: 503-371-0294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8731
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number8731
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: