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NPI Code Detail

MEDICARE: MS. MARYLOU WACEK

MEDICARE: MS. MARYLOU WACEK
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1183500000XPharmacist4981OR
21835P0018XPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist4981OR

General Provider Information

NPI Number : 1336408616
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. MARYLOU WACEK
Provider Business Mailing Address
First Line : 4849 NE 138TH AVE
Second Line :
City : PORTLAND
State : OR
Zip : 97230-3401
Country : US
Telephone Number : 503-257-3935
Fax Number : 503-257-3935
Provider Business Practice Location Address
First Line : 4849 NE 138TH AVE
Second Line :
City : PORTLAND
State : OR
Zip : 97230-3401
Country : US
Telephone Number : 503-257-3935
Fax Number : 503-253-3747
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/08/2012
Last Update Date : 12/31/2015

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Directions to “ MS. MARYLOU WACEK ” Practice Location

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