Healthcare Provider Details

I. General information

NPI: 1114768660
Provider Name (Legal Business Name): ROGUE HARTMAN PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2024
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 S ROOSEVELT DR
SEASIDE OR
97138-6745
US

IV. Provider business mailing address

1120 NAUTICAL DR
HAMMOND OR
97121-9102
US

V. Phone/Fax

Practice location:
  • Phone: 503-738-4706
  • Fax:
Mailing address:
  • Phone: 541-670-2513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH-0021020
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: