Organization
PROVIDENCE HEALTH & SERVICES OREGON
Active
Other names
Providence Bridgeport Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
DONALD WAYNE ANDERSON JR. (ASSISTANT SECREATRY FOR ENROLLMENT)
(425) 358-9786
Entity
Organization
Contact information
Practice address
18040 SW LOWER BOONES FERRY RD STE 104, TIGARD, OR 97224-7259
(503) 216-0625
(503) 216-0630
Mailing address
18040 SW LOWER BOONES FERRY RD, SUITE 104, TIGARD, OR 97224-7258
(503) 216-0625
(503) 216-0630
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
RP-0002571-CS
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
3843768
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
02/03/2010
Last updated
07/08/2025
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