Justin Tyler Miracle

Primary specialty

PharmacistTaxonomy code 183500000X

License

RPH0018483 Issued in OR

Practice address

777 NW Kings Blvd
Corvallis, OR 97330-5620

Phone

(541) 754-5583

NPI assigned

Oct 18, 2020

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Fred Meyer Stores Inc.

  • Community/Retail Pharmacy
  • Lynnwood, WA
  • NPI 1558235762
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1602979200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1700006400000",
    "number": "1497354880",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "777 NW KINGS BLVD",
            "city": "CORVALLIS",
            "state": "OR",
            "postal_code": "973305620",
            "telephone_number": "503-877-4430"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "777 NW KINGS BLVD",
            "city": "CORVALLIS",
            "state": "OR",
            "postal_code": "973305620",
            "telephone_number": "541-754-5583"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "3545 NE Canterbury Cir",
            "address_purpose": "LOCATION",
            "city": "Corvallis",
            "state": "OR",
            "postal_code": "973304007",
            "country_code": "US",
            "telephone_number": "503-877-4430",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "MIRACLE",
        "first_name": "JUSTIN",
        "middle_name": "TYLER",
        "name_prefix": "Mr.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2020-10-18",
        "last_updated": "2023-11-15",
        "certification_date": "2023-11-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": "OR",
            "license": "PI-0013024",
            "primary": false
        },
        {
            "code": "183500000X",
            "taxonomy_group": "",
            "desc": "Pharmacist",
            "state": "OR",
            "license": "RPH0018483",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Kyle Mindick, DO
• Josh Michael Miner, PT, DPT
• Melisa Miner
• Sandra Lynn Minta, PSY.D.
• Tiffani Roshawn Minter
• Gracenanci Rachel Miranda-Leon
• Kimberlyn M Misamore
• Abraham James Mitchell, BS
• Ashley Janette Mitchell
• Christopher Leon Mitchell Jr.

• Pharmacist in Corvallis, OR
• Providers in Corvallis, OR by specialty
• Pharmacist in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 15, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.