Provider Demographics
NPI:1588741458
Name:ASSURED PHARMACY GRESHAM INC
Entity type:Organization
Organization Name:ASSURED PHARMACY GRESHAM INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTING ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:JULIETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-668-7394
Mailing Address - Street 1:5760 LEGACY DR
Mailing Address - Street 2:STE. B3-518
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-7102
Mailing Address - Country:US
Mailing Address - Phone:972-668-7394
Mailing Address - Fax:866-232-1680
Practice Address - Street 1:831 NW COUNSIL DR
Practice Address - Street 2:STE 115
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030
Practice Address - Country:US
Practice Address - Phone:971-223-0552
Practice Address - Fax:503-492-2148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP00023663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3842590OtherNCPDP PROVIDER IDENTIFICATION NUMBER