MEDICARE: REBECCA ELIZABETH BLACK PHARMD

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	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	8957	OR

General Provider Information

NPI Number	:	1619286390
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCA ELIZABETH BLACK PHARMD

Provider Business Mailing Address
First Line	:	1448 BUCK ST
Second Line	:
City	:	WEST LINN
State	:	OR
Zip	:	97068-2706
Country	:	US
Telephone Number	:	801-244-4481
Fax Number	:

Provider Business Practice Location Address
First Line	:	3300 SE DWYER DR
Second Line	:	SUITE 304
City	:	MILWAUKIE
State	:	OR
Zip	:	97222-6548
Country	:	US
Telephone Number	:	503-513-8343
Fax Number	:

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

Provider Enumeration Date	:	09/29/2010
Last Update Date	:	09/29/2010

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