Provider Demographics
NPI:1891790549
Name:NICHOLLS, JUSTIN D (PHARMD, BCOP, BCPS)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:D
Last Name:NICHOLLS
Suffix:
Gender:M
Credentials:PHARMD, BCOP, BCPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 N PRESCOTT ST
Mailing Address - Street 2:APT 405
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-3202
Mailing Address - Country:US
Mailing Address - Phone:971-678-9127
Mailing Address - Fax:
Practice Address - Street 1:1201 NE LLOYD BLVD
Practice Address - Street 2:STE 510
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1202
Practice Address - Country:US
Practice Address - Phone:971-678-9127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-18
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3984183500000X
ORRPH-0010070183500000X, 183500000X
WAPH00052231183500000X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist