Basic Information
Provider Information | |||||||||
NPI: | 1912490582 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FAHEY | ||||||||
FirstName: | COLIN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1437 NW GROVE ST | ||||||||
Address2: |   | ||||||||
City: | ROSEBURG | ||||||||
State: | OR | ||||||||
PostalCode: | 974716147 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4582105704 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2700 NW STEWART PKWY | ||||||||
Address2: |   | ||||||||
City: | ROSEBURG | ||||||||
State: | OR | ||||||||
PostalCode: | 974711281 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5416730611 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2018 | ||||||||
LastUpdateDate: | 06/08/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | RPH-0016440 | OR | Y |   | Pharmacy Service Providers | Pharmacist |   |
ID Information
ID | Type | State | Issuer | Description | RPH-0016440 | 01 | OR | OREGON BOARD OF PHARMACY | OTHER |