Healthcare Provider Details

I. General information

NPI: 1740974534
Provider Name (Legal Business Name): MADELINE JEAN OWENS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MADELINE TYLER

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 08/03/2025
Certification Date: 08/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2280 MARCOLA RD
SPRINGFIELD OR
97477-2594
US

IV. Provider business mailing address

729 50TH AVE
SWEET HOME OR
97386-3209
US

V. Phone/Fax

Practice location:
  • Phone: 541-747-4300
  • Fax:
Mailing address:
  • Phone: 541-248-1559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberPI-0013933
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0020228
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: