Healthcare Provider Details

I. General information

NPI: 1114110178
Provider Name (Legal Business Name): JESSICA ANDERSON PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2007
Last Update Date: 04/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40520 COUNTY HIGHWAY 34
OGEMA MN
56569-9612
US

IV. Provider business mailing address

40520 COUNTY HIGHWAY 34
OGEMA MN
56569-9612
US

V. Phone/Fax

Practice location:
  • Phone: 218-983-6375
  • Fax: 218-983-6384
Mailing address:
  • Phone: 218-983-6375
  • Fax: 218-983-6384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number118927
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number118927
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: