Individual
MR. JUSTIN TYLER MIRACLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
777 NW KINGS BLVD, CORVALLIS, OR 97330-5620
(541) 754-5583
Mailing address
777 NW KINGS BLVD, CORVALLIS, OR 97330-5620
(503) 877-4430
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
Primary
RPH0018483
OR
390200000X
Student in an Organized Health Care Education/Training Program
PI-0013024
OR
Other
Enumeration date
10/18/2020
Last updated
11/15/2023
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