Provider Demographics
NPI:1063791879
Name:COSTELLO, JEFFREY BIRK (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:BIRK
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SE 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1753
Mailing Address - Country:US
Mailing Address - Phone:541-389-9741
Mailing Address - Fax:
Practice Address - Street 1:700 SE 3RD ST
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1753
Practice Address - Country:US
Practice Address - Phone:541-389-9741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-10
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRHP-0011948183500000X
ORRPH-00119481835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist