Healthcare Provider Details

I. General information

NPI: 1316659329
Provider Name (Legal Business Name): NICHOLAS JORGENSEN PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2022
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 N 10TH AVE
STAYTON OR
97383-1399
US

IV. Provider business mailing address

180 MELTON RD
CRESWELL OR
97426-9453
US

V. Phone/Fax

Practice location:
  • Phone: 503-769-2175
  • Fax: 503-769-5877
Mailing address:
  • Phone: 541-222-7700
  • Fax: 541-895-5426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH-0018556
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: