Provider Demographics
NPI:1396121265
Name:PECK, TANISHA (PHARM D)
Entity type:Individual
Prefix:
First Name:TANISHA
Middle Name:
Last Name:PECK
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 1:1775 THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2125
Mailing Address - Country:US
Mailing Address - Phone:541-269-4176
Mailing Address - Fax:541-269-8329
Practice Address - Street 1:1700 E 19TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3317
Practice Address - Country:US
Practice Address - Phone:541-269-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-03
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5294005-8911183500000X
ORRPH-00132071835X0200X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
No1835X0200XPharmacy Service ProvidersPharmacistOncology