Healthcare Provider Details

I. General information

NPI: 1275639437
Provider Name (Legal Business Name): AGNES KARI NILSEN PHARMACIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 THOMPSON RD
COOS BAY OR
97420-2125
US

IV. Provider business mailing address

3655 ASH ST
NORTH BEND OR
97459-1105
US

V. Phone/Fax

Practice location:
  • Phone: 541-269-8160
  • Fax: 541-269-0732
Mailing address:
  • Phone: 541-756-6979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number9257
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: