Healthcare Provider Details

I. General information

NPI: 1487038949
Provider Name (Legal Business Name): JORDAN MARIE BANISTER PHARM D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JORDAN MARIE SCHLICHT

II. Dates (important events)

Enumeration Date: 07/15/2015
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
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: 701-566-3466
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number122411
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number122411
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: