Licensee Name:PROVIDENCE SPECIALTY PHARMACY SERVICES
License Type:NON RESIDENT PHARMACY
License Number:1003
License Status:CLEAR Definition
Expiration Date:September 01, 2015
Issue Date:September 15, 2010
Address:6410 NE HALSEY STE 400
City:PORTLAND
State:OR
Zip:97213
County:OUT OF STATE
Actions:No
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