1588741458 NPI number — ASSURED PHARMACY GRESHAM INC

Table of content: (NPI 1588741458)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588741458 NPI number — ASSURED PHARMACY GRESHAM INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASSURED PHARMACY GRESHAM INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ASSURED PHARMACY GRESHAM
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588741458
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5760 LEGACY DR
Provider Second Line Business Mailing Address:
STE. B3-518
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75024-7102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-668-7394
Provider Business Mailing Address Fax Number:
866-232-1680

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
831 NW COUNSIL DR
Provider Second Line Business Practice Location Address:
STE 115
Provider Business Practice Location Address City Name:
GRESHAM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
971-223-0552
Provider Business Practice Location Address Fax Number:
503-492-2148
Provider Enumeration Date:
10/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
JULIETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
ACCOUNTING ANALYST
Authorized Official Telephone Number:
972-668-7394

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  RP0002366 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3842590 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".