Healthcare Provider Details

I. General information

NPI: 1497905772
Provider Name (Legal Business Name): FRED MEYER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2008
Last Update Date: 08/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22855 NE PARKLANE
WOOD VILLAGE OR
97060
US

IV. Provider business mailing address

22855 NE PARK LN
WOOD VILLAGE OR
97060-2606
US

V. Phone/Fax

Practice location:
  • Phone: 503-492-5033
  • Fax:
Mailing address:
  • Phone: 503-492-5033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10076
License Number StateOR

VIII. Authorized Official

Name: OANH NGO
Title or Position: PHARMACIST
Credential:
Phone: 503-492-5033