Healthcare Provider Details

I. General information

NPI: 1295069243
Provider Name (Legal Business Name): JAN HULTMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2009
Last Update Date: 09/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3909 SE HOLGATE BLVD
PORTLAND OR
97202-3143
US

IV. Provider business mailing address

3909 SE HOLGATE BLVD
PORTLAND OR
97202-3143
US

V. Phone/Fax

Practice location:
  • Phone: 503-206-5314
  • Fax:
Mailing address:
  • Phone: 503-206-5314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH-0011000
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: