=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215178462
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OUTSIDE IN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2009
-----------------------------------------------------
Last Update Date | 09/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1132 SW 13TH AVE
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97205-1703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-535-3888
-----------------------------------------------------
Fax | 503-610-3123
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1132 SW 13TH AVE
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97205-1703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-535-3888
-----------------------------------------------------
Fax | 503-610-3123
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACY MANAGER
-----------------------------------------------------
Name | MELINDA BUTLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 503-535-3888
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0002X
-----------------------------------------------------
Taxonomy Name | Clinic Pharmacy
-----------------------------------------------------
License Number | RP0002532CS
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------