Basic Information
Provider Information | |||||||||
NPI: | 1326568460 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HU | ||||||||
FirstName: | JACKIE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 MULLINS DR | ||||||||
Address2: |   | ||||||||
City: | LEBANON | ||||||||
State: | OR | ||||||||
PostalCode: | 973553983 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412590235 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 124 LANCASTER DR SE | ||||||||
Address2: |   | ||||||||
City: | SALEM | ||||||||
State: | OR | ||||||||
PostalCode: | 973175331 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5034285004 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/20/2017 | ||||||||
LastUpdateDate: | 07/14/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/14/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | S022711 | AZ | N |   | Pharmacy Service Providers | Pharmacist |   | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 183500000X | RPH-0017925 | OR | Y |   | Pharmacy Service Providers | Pharmacist |   |
No ID Information.