Healthcare Provider Details

I. General information

NPI: 1861646929
Provider Name (Legal Business Name): JENNIFER FORDICE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2008
Last Update Date: 11/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38241 PROCTOR BLVD
SANDY OR
97055-8019
US

IV. Provider business mailing address

38241 PROCTOR BLVD
SANDY OR
97055-8019
US

V. Phone/Fax

Practice location:
  • Phone: 503-668-1384
  • Fax:
Mailing address:
  • Phone: 503-668-1384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH-0011407
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: