=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144553322
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERICK MATTHEW ALSVIG
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2009
-----------------------------------------------------
Last Update Date | 09/06/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16200 NE GLISAN ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97230-5833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-251-8995
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16200 NE GLISAN ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97230-5833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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-0011555
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------