Provider Demographics
NPI:1104121938
Name:COLUMBIA PHARMACY LLC
Entity type:Organization
Organization Name:COLUMBIA PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HANH
Authorized Official - Middle Name:H
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-245-5010
Mailing Address - Street 1:8122 SE TIBBETTS ST.
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206
Mailing Address - Country:US
Mailing Address - Phone:503-777-7055
Mailing Address - Fax:503-384-2417
Practice Address - Street 1:8122 SE TIBBETTS ST.
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206
Practice Address - Country:US
Practice Address - Phone:503-777-7055
Practice Address - Fax:503-384-2417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-26
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500634523Medicaid