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Individual

MR. RYAN AMOS MICKELSON

Active
Sole proprietor
No

Provider details

NPI number
Gender
Man
Credential
PHARMD, BCPS

Contact information

Practice address
3750 CHEMAWA RD NE, SALEM, OR 97305-1119
(503) 304-7600
Mailing address
245 SW HOOKER ST, APT 1, PORTLAND, OR 97201-4774
(608) 212-9204

Taxonomy

Speciality
Code
Description
License number
State
183500000X
Pharmacist
15475-040
WI
183500000X
Pharmacist
Primary
RPH-0011121
OR
1835P1200X
Pharmacotherapy Pharmacist
BCPS 308009953
OR

Other

Enumeration date
01/16/2010
Last updated
01/16/2010
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