Healthcare Provider Details

I. General information

NPI: 1376104604
Provider Name (Legal Business Name): JESSE ROBERT OBRIGHT PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 07/05/2024
Certification Date: 07/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1921 COBORN BLVD
SAINT CLOUD MN
56301-2100
US

IV. Provider business mailing address

1921 COBORN BLVD
SAINT CLOUD MN
56301-2100
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-4222
  • Fax:
Mailing address:
  • Phone: 320-252-4222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number123280
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: