Provider Demographics
NPI:1235869488
Name:MINDRX, LLC
Entity type:Organization
Organization Name:MINDRX, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIPPO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-664-9451
Mailing Address - Street 1:3055 NW YEON AVE SUITE 606
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210
Mailing Address - Country:US
Mailing Address - Phone:503-664-9451
Mailing Address - Fax:
Practice Address - Street 1:555 SE MLK JR BLVD UNIT 105
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2595
Practice Address - Country:US
Practice Address - Phone:503-664-9451
Practice Address - Fax:503-386-3230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-11
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP60805213OtherLICENSE (WASHINGTON)
OR201903897NP-PPOtherLICENSE