Healthcare Provider Details

I. General information

NPI: 1750609814
Provider Name (Legal Business Name): JON A NIELSEN PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 12/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 7TH AVE
LONGVIEW WA
98632-3166
US

IV. Provider business mailing address

1230 7TH AVE
LONGVIEW WA
98632-3166
US

V. Phone/Fax

Practice location:
  • Phone: 360-575-4841
  • Fax:
Mailing address:
  • Phone: 360-575-4841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH60163314
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number6302
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH-0013019
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRPH-0013019
License Number StateOR
# 5
Primary TaxonomyN
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberPH60163314
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: