Provider Demographics
NPI:1619215068
Name:NELSON, BART D (RPH)
Entity Type:Individual
Prefix:MR
First Name:BART
Middle Name:D
Last Name:NELSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:MR
Other - First Name:BARTON
Other - Middle Name:DOUGLAS
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:301 BLUE OAK LN
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-2105
Mailing Address - Country:US
Mailing Address - Phone:650-269-0056
Mailing Address - Fax:
Practice Address - Street 1:255 2ND ST
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94022-3627
Practice Address - Country:US
Practice Address - Phone:650-948-1212
Practice Address - Fax:650-949-2269
Is Sole Proprietor?:No
Enumeration Date:2013-01-18
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 27042183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist