Provider Demographics
NPI:1396290201
Name:NELSON, GARY EDWIN (RPH)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:EDWIN
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 1:3667 SE DURANGO PL
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-7357
Mailing Address - Country:US
Mailing Address - Phone:503-341-2712
Mailing Address - Fax:
Practice Address - Street 1:1700 NE 102ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-3804
Practice Address - Country:US
Practice Address - Phone:866-279-4581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-20
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR70221835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist