Provider Demographics
NPI:1275764482
Name:NELSEN, GREGORY
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:NELSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 E 650 N
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-5035
Mailing Address - Country:US
Mailing Address - Phone:623-687-1562
Mailing Address - Fax:
Practice Address - Street 1:253 E 650 N
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-5035
Practice Address - Country:US
Practice Address - Phone:623-687-1562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-05
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORP-001165183500000X
IDP6278183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist