Provider Demographics
NPI:1316355357
Name:NIVISON, JOHN (PHARMACIST)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:NIVISON
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20452 PINE VISTA DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-9437
Mailing Address - Country:US
Mailing Address - Phone:541-420-5329
Mailing Address - Fax:
Practice Address - Street 1:2091 NE 3RD ST
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-8130
Practice Address - Country:US
Practice Address - Phone:541-447-0395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-22
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5790183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist