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General NPI Number Information
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NPI Number | 1891319323
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Entity Type | Individual
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Provider Name | WINONA-REBEKAH BLANCO MARATITA-LIZAMA
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Gender | Female
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Dates
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Enumeration Date | 06/01/2020
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Last Update Date | 03/16/2024
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Provider Practice Location Address
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Address Line | 8122 SE TIBBETTS ST
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City | PORTLAND
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State | OR
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Zip | 97206-1768
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Country | US
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Telephone | 503-777-7055
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Fax |
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Provider Business Mailing Address
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Address Line | 1815 4TH ST
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City | TILLAMOOK
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State | OR
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Zip | 97141-2210
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Country | US
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Telephone | 503-842-5934
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | RPH-0017811
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License Number State | OR
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