Healthcare Provider Details

I. General information

NPI: 1891790549
Provider Name (Legal Business Name): JUSTIN D NICHOLLS PHARMD, BCOP, BCPS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2005
Last Update Date: 10/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 NE LLOYD BLVD STE 510
PORTLAND OR
97232-1202
US

IV. Provider business mailing address

1450 N PRESCOTT ST APT 405
PORTLAND OR
97217-3202
US

V. Phone/Fax

Practice location:
  • Phone: 971-678-9127
  • Fax:
Mailing address:
  • Phone: 971-678-9127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number3984
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH-0010070
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH00052231
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: