=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497123756
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELAINE ENWARDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2015
-----------------------------------------------------
Last Update Date | 09/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3300 W 6TH ST
-----------------------------------------------------
City | THE DALLES
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97058-4144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-298-2055
-----------------------------------------------------
Fax | 541-298-2060
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3300 W 6TH ST
-----------------------------------------------------
City | THE DALLES
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97058-4144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-298-2055
-----------------------------------------------------
Fax | 541-298-2060
-----------------------------------------------------
=====================================================
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-0014492
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PH-00011866
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------