Provider Demographics
NPI:1316235633
Name:WAIGUCHU JACKSON, ELIZABETH M (PHARMD, RPH)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:M
Last Name:WAIGUCHU JACKSON
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 823003
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-0063
Mailing Address - Country:US
Mailing Address - Phone:503-801-7521
Mailing Address - Fax:
Practice Address - Street 1:13010 SW 68TH PKWY STE 140
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-9621
Practice Address - Country:US
Practice Address - Phone:503-210-2548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-20
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0011663183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist