Healthcare Provider Details

I. General information

NPI: 1396905022
Provider Name (Legal Business Name): JAY HENRY EIDEM PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2008
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E 28TH ST STE H2100
MINNEAPOLIS MN
55407
US

IV. Provider business mailing address

800 E 28TH ST # 33230
MINNEAPOLIS MN
55407-3723
US

V. Phone/Fax

Practice location:
  • Phone: 612-863-9134
  • Fax: 612-863-3646
Mailing address:
  • Phone: 952-212-8086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number118893
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: