Healthcare Provider Details

I. General information

NPI: 1962462960
Provider Name (Legal Business Name): GLSJO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33454 SW CHINOOK PLZ
SCAPPOOSE OR
97056-3731
US

IV. Provider business mailing address

916 W EVERGREEN BLVD
VANCOUVER WA
98660-3035
US

V. Phone/Fax

Practice location:
  • Phone: 503-543-6316
  • Fax: 360-213-2238
Mailing address:
  • Phone: 360-213-2236
  • Fax: 360-213-2238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberRP0000553CS
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3804780
Identifier TypeOTHER
Identifier State
Identifier IssuerNCPDP
# 2
Identifier175026
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: KRISTI VEIS
Title or Position: VP OF PHARMACY
Credential:
Phone: 503-507-6073