# WILLAMETTE PAIN & SPINE CENTER PC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Sunnyside Pharmacy
- **Organization subpart:** No

## Provider details

- **NPI number:** 1114312451
- **Authorized official:** TAMMIE MISKIMINS (MGR, LICENSING & THIRD PARTY)
- **Authorized official phone:** (817) 572-0009

## Contact information

- **Practice address:** 10001 SE SUNNYSIDE RD STE 100A, CLACKAMAS, OR 97015-9728
- **Practice address phone:** (503) 343-9363
- **Mailing address:** 1620 W. NORTHWEST HWY, STE. 100, GRAPEVINE, TX 76051
- **Mailing address phone:** (817) 572-0009
- **Mailing address fax:** (817) 720-1039

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 3336C0003X | Community/Retail Pharmacy | RP0003062CS | OR | Yes |

## Other

- **Enumeration date:** 04/03/2015
- **Last updated:** 06/29/2016

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 2151143 | PK | — |