Provider Demographics
NPI:1225851934
Name:BURGIS, JACOB DOUGLAS (RPH)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:DOUGLAS
Last Name:BURGIS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11671 SW TEAL BLVD APT G
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-8248
Mailing Address - Country:US
Mailing Address - Phone:661-349-5721
Mailing Address - Fax:
Practice Address - Street 1:19200 SW MARTINAZZI AVE
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-6357
Practice Address - Country:US
Practice Address - Phone:503-691-4233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-02
Last Update Date:2024-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0020309183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist