Provider Demographics
NPI:1104164433
Name:DUBE, SUSANNA LYN (PHARM D)
Entity type:Individual
Prefix:
First Name:SUSANNA
Middle Name:LYN
Last Name:DUBE
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 PORTLAND RD
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-5400
Mailing Address - Country:US
Mailing Address - Phone:503-537-1383
Mailing Address - Fax:
Practice Address - Street 1:3300 PORTLAND RD
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-5400
Practice Address - Country:US
Practice Address - Phone:503-537-1383
Practice Address - Fax:503-537-1377
Is Sole Proprietor?:No
Enumeration Date:2013-01-22
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0010715183500000X
WAPH 00039967183500000X
OR00107151835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist