Provider Demographics
NPI:1972615987
Name:HILLSBORO PHARMACY & FOUNTAIN
Entity type:Organization
Organization Name:HILLSBORO PHARMACY & FOUNTAIN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASMINE
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-450-9194
Mailing Address - Street 1:155 SE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4026
Mailing Address - Country:US
Mailing Address - Phone:503-648-1811
Mailing Address - Fax:503-640-1514
Practice Address - Street 1:155 SE 2ND AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4026
Practice Address - Country:US
Practice Address - Phone:503-648-1811
Practice Address - Fax:503-640-1514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
ORRP-0000237-CS3336C0003X
ORNPA-00069893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2077319OtherPK
OR083758Medicaid