Healthcare Provider Details

I. General information

NPI: 1578856969
Provider Name (Legal Business Name): THERESA TAIT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2011
Last Update Date: 01/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25900 SW HEATHER PL
WILSONVILLE OR
97070-5785
US

IV. Provider business mailing address

13130 SE 84TH AVE
CLACKAMAS OR
97015-9733
US

V. Phone/Fax

Practice location:
  • Phone: 503-825-4005
  • Fax: 503-825-4023
Mailing address:
  • Phone: 503-794-5520
  • Fax: 503-794-5528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0009311
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number0009311
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: