Provider Demographics
NPI:1023507613
Name:DIBOS, NICHOLAS RYAN
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:RYAN
Last Name:DIBOS
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:PO BOX 2767
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-0308
Mailing Address - Country:US
Mailing Address - Phone:541-744-1641
Mailing Address - Fax:541-744-1052
Practice Address - Street 1:1750 WILLOW CREEK CIR
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-9152
Practice Address - Country:US
Practice Address - Phone:541-744-1641
Practice Address - Fax:541-744-1052
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0013146183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist