Provider Demographics
NPI:1063401198
Name:GRESHAM PROFESSIONAL PHARMACY
Entity type:Organization
Organization Name:GRESHAM PROFESSIONAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:MOLL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:503-491-0117
Mailing Address - Street 1:24076 SE STARK ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-3373
Mailing Address - Country:US
Mailing Address - Phone:503-491-0117
Mailing Address - Fax:503-489-2078
Practice Address - Street 1:24076 SE STARK ST
Practice Address - Street 2:SUITE 100
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3373
Practice Address - Country:US
Practice Address - Phone:503-491-0117
Practice Address - Fax:503-489-2078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8305183500000X
OR0021023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR299911Medicaid
OR3815125OtherNABP/NCPDP #