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General NPI Number Information
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NPI Number | 1891790549
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Entity Type | Individual
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Provider Name | JUSTIN D NICHOLLS PHARMD, BCOP, BCPS
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Gender | Male
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Dates
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Enumeration Date | 06/18/2005
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Last Update Date | 10/17/2014
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Provider Practice Location Address
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Address Line | 1201 NE LLOYD BLVD STE 510
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City | PORTLAND
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State | OR
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Zip | 97232-1202
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Country | US
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Telephone | 971-678-9127
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Fax |
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Provider Business Mailing Address
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Address Line | 1450 N PRESCOTT ST APT 405
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City | PORTLAND
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State | OR
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Zip | 97217-3202
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Country | US
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Telephone | 971-678-9127
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 3984
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License Number State | MT
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | RPH-0010070
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | PH00052231
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License Number State | WA
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