MEDICARE: MR. IAN LEONARD BLACK RPH

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
1	183500000X	Pharmacist	RPH-0007673-P	OR

General Provider Information

NPI Number	:	1508205816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. IAN LEONARD BLACK RPH

Provider Business Mailing Address
First Line	:	PO BOX 280
Second Line	:
City	:	SUTHERLIN
State	:	OR
Zip	:	97479-0280
Country	:	US
Telephone Number	:	541-459-2712
Fax Number	:	541-459-9129

Provider Business Practice Location Address
First Line	:	113 E CENTRAL AVE
Second Line	:
City	:	SUTHERLIN
State	:	OR
Zip	:	97479-9556
Country	:	US
Telephone Number	:	541-459-2712
Fax Number	:	541-459-9129

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2013
Last Update Date	:	06/19/2013

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