Provider Demographics
NPI:1487471892
Name:SMITH, CULLEN MCCLAY (PHARMD)
Entity type:Individual
Prefix:
First Name:CULLEN
Middle Name:MCCLAY
Last Name:SMITH
Suffix:
Gender:X
Credentials:PHARMD
Other - Prefix:
Other - First Name:CULLEN
Other - Middle Name:MCCLAY
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMD
Mailing Address - Street 1:1878 SE 104TH CT
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2910
Mailing Address - Country:US
Mailing Address - Phone:503-793-1863
Mailing Address - Fax:
Practice Address - Street 1:6025 JEAN RD
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5307
Practice Address - Country:US
Practice Address - Phone:503-303-7373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP10723183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty