Healthcare Provider Details

I. General information

NPI: 1124233267
Provider Name (Legal Business Name): JAN ALVIN NELSON RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 WEST JESSIE STREET
RUSHFORD MN
55971
US

IV. Provider business mailing address

526 OLMSTEAD ST
WINONA MN
55987-2932
US

V. Phone/Fax

Practice location:
  • Phone: 507-864-2153
  • Fax: 507-864-2143
Mailing address:
  • Phone: 507-454-7168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number113081
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: