Active NPI
Thayne Edward Vickstrom
- Pharmacist
- Corvallis, OR
National Provider Identifier
1265705768
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- 9544
- Practice address
- 1555 SW 53Rd St
Corvallis, OR 97333-2630 - Phone
- (541) 758-3392
- Fax
- (541) 758-4159
- NPI assigned
- Feb 14, 2012
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | 9544 | OR | Primary |
Addresses
Primary practice location
1555 SW 53Rd St
Corvallis, OR 97333-2630
Mailing address
1555 SW 53Rd St
Corvallis, OR 97333-2630
Phone (541) 758-3392
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 9544 | Other | OR | STATE PHARMACIST LICENSE |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 9544 | OR | MD | Pharmacist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1329177600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1329177600000",
"number": "1265705768",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1555 SW 53RD ST",
"city": "CORVALLIS",
"state": "OR",
"postal_code": "973332630",
"telephone_number": "541-758-3392",
"fax_number": "541-758-4159"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1555 SW 53RD ST",
"city": "CORVALLIS",
"state": "OR",
"postal_code": "973332630",
"telephone_number": "541-758-3392",
"fax_number": "541-758-4159"
}
],
"practiceLocations": [],
"basic": {
"last_name": "VICKSTROM",
"first_name": "THAYNE",
"middle_name": "EDWARD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2012-02-14",
"last_updated": "2012-02-14",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "OR",
"license": "9544",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "STATE PHARMACIST LICENSE",
"identifier": "9544",
"state": "OR"
}
],
"endpoints": [],
"other_names": []
}Other providers in Corvallis, OR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 14, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.