1457311698 NPI number — ASTORIA FAMILY PHARMACY, LLC

Table of content: (NPI 1457311698)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457311698 NPI number — ASTORIA FAMILY PHARMACY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASTORIA FAMILY PHARMACY, 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:
1457311698
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
916 W EVERGREEN BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98660-3035
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-213-2236
Provider Business Mailing Address Fax Number:
360-213-2238

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2120 EXCHANGE ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
ASTORIA
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97103-3365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-325-3455
Provider Business Practice Location Address Fax Number:
503-325-3473
Provider Enumeration Date:
03/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OLIVA
Authorized Official First Name:
STEVE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
360-693-5879

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  RP0001690CS , 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: 226560 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3814111 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".




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