Active NPI
Shinta Imansjah, PHARM D/RPH
- Pharmacist
- Portland, OR
National Provider Identifier
1457314353
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- RPH-0015242
- Practice address
- 12360 E Burnside St
Portland, OR 97233-1042 - Phone
- (971) 279-4800
- Fax
- (971) 279-2763
- NPI assigned
- Apr 11, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 3
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | PH61290107 | WA | |
| Pharmacist | 183500000X | PS 40904 | FL | |
| Pharmacist | 183500000X | RPH-0015242 | OR | Primary |
Addresses
Primary practice location
12360 E Burnside St
Portland, OR 97233-1042
Mailing address
211 SE Caruthers St
Portland, OR 97214-4502
Phone (503) 224-1044
Other practice location 1
703 NE Hancock St
Portland, OR 97212-3955
Phone (503) 230-9875
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 500722920 | Medicaid | OR | |
| 2306886 | Medicaid | WA |
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
- Credentials
- Doctor of Pharmacy, Registered Pharmacist
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PS 40904 | FL | MD | Pharmacist |
| RPH-0015242 | OR | MD | Pharmacist |
| PH61290107 | WA | MD | Pharmacist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1144713600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1744156800000",
"number": "1457314353",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "211 SE CARUTHERS ST",
"city": "PORTLAND",
"state": "OR",
"postal_code": "972144502",
"telephone_number": "503-224-1044",
"fax_number": "971-260-0355"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "12360 E BURNSIDE ST",
"city": "PORTLAND",
"state": "OR",
"postal_code": "972331042",
"telephone_number": "971-279-4800",
"fax_number": "971-279-2763"
}
],
"practiceLocations": [
{
"address_1": "703 NE Hancock St",
"address_purpose": "LOCATION",
"city": "Portland",
"state": "OR",
"postal_code": "972123955",
"country_code": "US",
"telephone_number": "503-230-9875",
"fax_number": "503-331-2677",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "IMANSJAH",
"first_name": "SHINTA",
"credential": "PHARM D/RPH",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-04-11",
"last_updated": "2025-04-09",
"certification_date": "2025-04-09",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "WA",
"license": "PH61290107",
"primary": false
},
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "FL",
"license": "PS 40904",
"primary": false
},
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "OR",
"license": "RPH-0015242",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "500722920",
"state": "OR"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "2306886",
"state": "WA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Portland, OR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 9, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.