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General NPI Number Information
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NPI Number | 1588917447
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Entity Type | Organization
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Legal Business Name | MPKM, LLC
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Dates
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Enumeration Date | 10/17/2012
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Last Update Date | 10/17/2012
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Provider Practice Location Address
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Address Line | 10000 SE MAIN ST STE 118
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City | PORTLAND
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State | OR
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Zip | 97216-2462
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Country | US
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Telephone | 702-203-4797
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Fax |
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Provider Business Mailing Address
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Address Line | 608 SARI DR
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City | LAS VEGAS
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State | NV
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Zip | 89110-4227
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Country | US
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Telephone | 702-203-4797
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. MATTHEW HOGAN PETERS
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Credential |
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Telephone | 702-203-4797
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | RP0000689-C
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License Number State | OR
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