Provider Demographics
NPI:1124233267
Name:NELSON, JAN ALVIN (RPH)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:ALVIN
Last Name:NELSON
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 1:526 OLMSTEAD ST
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-2932
Mailing Address - Country:US
Mailing Address - Phone:507-454-7168
Mailing Address - Fax:
Practice Address - Street 1:115 WEST JESSIE STREET
Practice Address - Street 2:
Practice Address - City:RUSHFORD
Practice Address - State:MN
Practice Address - Zip Code:55971
Practice Address - Country:US
Practice Address - Phone:507-864-2153
Practice Address - Fax:507-864-2143
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN113081183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist