=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497124135
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RITE AID PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2015
-----------------------------------------------------
Last Update Date | 09/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7440 N DENVER AVE
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97217-5630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-286-5680
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20718 SW SISTER LN
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97003-8155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACY DISTRICT MANAGER
-----------------------------------------------------
Name | ANAND GOWDA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 425-247-4108
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | RPH0014876
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------