Provider Demographics
NPI:1366055246
Name:NINIVAGGI, SETH ALAN (PHARMD)
Entity type:Individual
Prefix:
First Name:SETH
Middle Name:ALAN
Last Name:NINIVAGGI
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 1:11674 SW WILTON AVE
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-1657
Mailing Address - Country:US
Mailing Address - Phone:775-750-4058
Mailing Address - Fax:
Practice Address - Street 1:7010 NE CORNELL RD
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-5422
Practice Address - Country:US
Practice Address - Phone:503-693-0109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0017842183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist