Healthcare Provider Details

I. General information

NPI: 1740702562
Provider Name (Legal Business Name): JESSICA PAN LIU PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2017
Last Update Date: 07/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5428 LYNDALE AVE S
MINNEAPOLIS MN
55419-1718
US

IV. Provider business mailing address

5428 LYNDALE AVE S
MINNEAPOLIS MN
55419-1718
US

V. Phone/Fax

Practice location:
  • Phone: 612-824-1121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number123414
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: