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General NPI Number Information
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NPI Number | 1639651490
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Entity Type | Organization
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Legal Business Name | BEAVERTON PHARMACY INC
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Dates
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Enumeration Date | 08/29/2018
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Last Update Date | 08/29/2018
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Provider Practice Location Address
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Address Line | 12250 SW CANYON RD
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City | BEAVERTON
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State | OR
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Zip | 97005-2116
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Country | US
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Telephone | 503-644-2101
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Fax |
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Provider Business Mailing Address
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Address Line | 12250 SW CANYON RD
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City | BEAVERTON
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State | OR
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Zip | 97005-2116
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Country | US
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Telephone | 503-644-2101
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | THOMAS WADE IRBY
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Credential | RPH
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Telephone | 503-644-2101
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number | RP-0000129-CS
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License Number State | OR
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