Individual
THAYNE EDWARD VICKSTROM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
1555 SW 53RD ST, CORVALLIS, OR 97333-2630
(541) 758-3392
(541) 758-4159
Mailing address
1555 SW 53RD ST, CORVALLIS, OR 97333-2630
(541) 758-3392
(541) 758-4159
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
Primary
9544
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
9544
STATE PHARMACIST LICENSE
OR
Enumeration date
02/14/2012
Last updated
02/14/2012
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