Healthcare Provider Details

I. General information

NPI: 1598490385
Provider Name (Legal Business Name): JADEY RISOVI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 5TH ST NE STE 2
DEVILS LAKE ND
58301-2476
US

IV. Provider business mailing address

2475 32ND AVE S STE 1
GRAND FORKS ND
58201-3606
US

V. Phone/Fax

Practice location:
  • Phone: 701-662-3022
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH6425
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: