=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063970929
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY R PLANTE PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2019
-----------------------------------------------------
Last Update Date | 04/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3600 NW SAMARITAN DR
-----------------------------------------------------
City | CORVALLIS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97330-5472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-768-5071
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4480 LONE OAK RD SE
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97302-4839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-336-0254
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RPH-0018166
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | P8885
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | RPH-0018166
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------