Provider Demographics
NPI:1598211393
Name:JIVAGUNCHAINAN, SATTA
Entity type:Individual
Prefix:
First Name:SATTA
Middle Name:
Last Name:JIVAGUNCHAINAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7404 N INTERSTATE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-5528
Mailing Address - Country:US
Mailing Address - Phone:503-286-6784
Mailing Address - Fax:
Practice Address - Street 1:1111 NE 102ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-3902
Practice Address - Country:US
Practice Address - Phone:503-255-5494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0015543183500000X
OR155431835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist