1174133300 NPI number — PEACEHEALTH NETWORKS ON DEMAND, LLC

Table of content: (NPI 1174133300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174133300 NPI number — PEACEHEALTH NETWORKS ON DEMAND, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEACEHEALTH NETWORKS ON DEMAND, LLC
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:
Provider Other Organization Name Type Code:
6
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:
1174133300
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11958 SW GARDEN PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TIGARD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97223-8248
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-684-8252
Provider Business Mailing Address Fax Number:
866-859-8195

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7855 SW CAPITOL HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97219-2465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-684-8252
Provider Business Practice Location Address Fax Number:
833-450-8484
Provider Enumeration Date:
08/03/2020

Additional Information

Authorized Official

Authorized Official Last Name:
KEMPTON-HEIN
Authorized Official First Name:
MALLORY
Authorized Official Middle Name:
ALYSE
Authorized Official Title or Position:
PHARMACIST
Authorized Official Telephone Number:
503-684-8252

Provider Taxonomy Codes

  • Taxonomy code: 332900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0000072 . This is a "DISPENSING PRACTITIONER DRUG OUTLET" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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