Healthcare Provider Details

I. General information

NPI: 1407304991
Provider Name (Legal Business Name): JOSHUA SEIDEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 MT HOOD ST
THE DALLES OR
97058
US

IV. Provider business mailing address

515 MT HOOD ST
THE DALLES OR
97058
US

V. Phone/Fax

Practice location:
  • Phone: 541-296-3190
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0015521
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: