Provider Demographics
NPI:1386084515
Name:FUNATAKE, CAROL A
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:FUNATAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14700 SE MCLOUGHLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267-1417
Mailing Address - Country:US
Mailing Address - Phone:503-652-4133
Mailing Address - Fax:503-652-4120
Practice Address - Street 1:14700 SE MCLOUGHLIN BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-1417
Practice Address - Country:US
Practice Address - Phone:503-652-4133
Practice Address - Fax:503-652-4120
Is Sole Proprietor?:No
Enumeration Date:2013-07-02
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6280183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist