Provider Demographics
NPI:1548045750
Name:LI, BRYANT
Entity type:Individual
Prefix:
First Name:BRYANT
Middle Name:
Last Name:LI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 NE MULTNOMAH ST APT 405
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-3611
Mailing Address - Country:US
Mailing Address - Phone:925-895-1512
Mailing Address - Fax:
Practice Address - Street 1:5717 NE 138TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-3499
Practice Address - Country:US
Practice Address - Phone:503-821-1166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2024-10-15
Deactivation Date:2024-09-22
Deactivation Code:
Reactivation Date:2024-10-11
Provider Licenses
StateLicense IDTaxonomies
CAINT49182183500000X
WAPH615675191835P0018X
ORRPH-00202391835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist