=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255564449
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW EVANS PAXSON PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2009
-----------------------------------------------------
Last Update Date | 09/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1704 E MAIN ST
-----------------------------------------------------
City | COTTAGE GROVE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97424-2244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-942-2224
-----------------------------------------------------
Fax | 541-942-8274
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1704 E MAIN ST
-----------------------------------------------------
City | COTTAGE GROVE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97424-2244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-942-2224
-----------------------------------------------------
Fax | 541-942-8274
-----------------------------------------------------
=====================================================
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-0011178
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------