MEDICARE: EDWARD MICK 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	RPH-0013551	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841770211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD MICK PHARMD

Provider Business Mailing Address
First Line	:	9640 SW SHADY PL
Second Line	:
City	:	TIGARD
State	:	OR
Zip	:	97223-1132
Country	:	US
Telephone Number	:	503-730-3283
Fax Number	:

Provider Business Practice Location Address
First Line	:	1455 NW IRVING ST STE 500
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97209-2277
Country	:	US
Telephone Number	:	503-941-3807
Fax Number	:

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

Provider Enumeration Date	:	08/15/2018
Last Update Date	:	08/15/2018

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Directions to “ EDWARD MICK PHARMD” Practice Location

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