Provider Demographics
NPI:1508205816
Name:BLACK, IAN LEONARD (RPH)
Entity type:Individual
Prefix:MR
First Name:IAN
Middle Name:LEONARD
Last Name:BLACK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:SUTHERLIN
Mailing Address - State:OR
Mailing Address - Zip Code:97479-0280
Mailing Address - Country:US
Mailing Address - Phone:541-459-2712
Mailing Address - Fax:541-459-9129
Practice Address - Street 1:113 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SUTHERLIN
Practice Address - State:OR
Practice Address - Zip Code:97479-9556
Practice Address - Country:US
Practice Address - Phone:541-459-2712
Practice Address - Fax:541-459-9129
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-19
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0007673-P183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist