Healthcare Provider Details

I. General information

NPI: 1356635635
Provider Name (Legal Business Name): JENELLE M BOESCH PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2011
Last Update Date: 06/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

749 APOLLO DR T1448
LINO LAKES MN
55014-3035
US

IV. Provider business mailing address

749 APOLLO DR T1448
LINO LAKES MN
55014-3035
US

V. Phone/Fax

Practice location:
  • Phone: 651-784-7618
  • Fax:
Mailing address:
  • Phone: 651-784-7618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number118931
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: