Basic Information
| Provider Information | |||||||||
| NPI: | 1144839804 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEACEHEALTH NETWORKS ON DEMAND, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1455 NW IRVING ST STE 600 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972092277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039413807 | ||||||||
| FaxNumber: | 5039413809 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 NE ALBERTA ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972115044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036848252 | ||||||||
| FaxNumber: | 8668598195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2020 | ||||||||
| LastUpdateDate: | 07/29/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KEMPTON-HEIN | ||||||||
| AuthorizedOfficialFirstName: | MALLORY | ||||||||
| AuthorizedOfficialMiddleName: | ALYSE | ||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACIST | ||||||||
| AuthorizedOfficialTelephone: | 5039413807 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PEACEHEALTH NETWORKS ON DEMAND, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHARM D. | ||||||||
| NPICertificationDate: | 07/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
ID Information
| ID | Type | State | Issuer | Description | 0000001-CS | 01 | OR | SUPERVISING PHYSICIAN DISPENSING OUTLET LICENSE | OTHER |