Basic Information
| Provider Information | |||||||||
| NPI: | 1568893303 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEONG | ||||||||
| FirstName: | PATRICK | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHARMACIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 421 SW OAK ST | ||||||||
| Address2: | STE. 210 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972041817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039887468 | ||||||||
| FaxNumber: | 5039883015 | ||||||||
| Practice Location | |||||||||
| Address1: | 421 SW OAK ST | ||||||||
| Address2: | STE. 210 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972041817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039887468 | ||||||||
| FaxNumber: | 5039883015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2013 | ||||||||
| LastUpdateDate: | 12/04/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P0018X | RPH-0012487 | OR | Y | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist |
ID Information
| ID | Type | State | Issuer | Description | 22959 | 05 | OR | MEDICAID | 096511 | 05 | OR | MEDICAID |