Provider Demographics
NPI:1093996431
Name:NIELSEN, JEFFREY L (RPH)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:L
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 N 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-0444
Mailing Address - Country:US
Mailing Address - Phone:605-373-4813
Mailing Address - Fax:605-373-4866
Practice Address - Street 1:4901 N 4TH AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-0444
Practice Address - Country:US
Practice Address - Phone:605-373-4813
Practice Address - Fax:605-373-4866
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4782183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD4782OtherSTATE OF SD BOP LICENSE