Healthcare Provider Details

I. General information

NPI: 1407836489
Provider Name (Legal Business Name): LARRY STEVEN BLANK RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WESTERN OREGON SERVICE UNIT CHEMAWA INDIAN HEALTH CENTER
SALEM OR
97305-1111
US

IV. Provider business mailing address

131 NW 20TH ST STE D
NEWPORT OR
97365
US

V. Phone/Fax

Practice location:
  • Phone: 503-304-7600
  • Fax: 503-304-7678
Mailing address:
  • Phone: 503-304-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number9431
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: