Healthcare Provider Details

I. General information

NPI: 1932609245
Provider Name (Legal Business Name): NICOLE KEPNER PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2018
Last Update Date: 04/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 CENTENNIAL BLVD
SPRINGFIELD OR
97477
US

IV. Provider business mailing address

1600 VALLEY RIVER DR STE 210
EUGENE OR
97401-2155
US

V. Phone/Fax

Practice location:
  • Phone: 541-747-4300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03237138
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number00117124
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number00117124
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: