Basic Information
| Provider Information | |||||||||
| NPI: | 1366773467 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLEESON | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 307 C AVE | ||||||||
| Address2: | |||||||||
| City: | LA GRANDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978501136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419630496 | ||||||||
| FaxNumber: | 5419630278 | ||||||||
| Practice Location | |||||||||
| Address1: | 73265 CONFEDERATED WAY | ||||||||
| Address2: | |||||||||
| City: | PENDLETON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412787505 | ||||||||
| FaxNumber: | 5412787572 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2010 | ||||||||
| LastUpdateDate: | 01/29/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | RPH0006700 | OR | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 171037 | 05 | OR | MEDICAID |