Healthcare Provider Details

I. General information

NPI: 1972852747
Provider Name (Legal Business Name): JERILYN ANN KLEIN WANGEN PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2012
Last Update Date: 09/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 38TH ST NW STE A
FARGO ND
58102-2955
US

IV. Provider business mailing address

712 38TH ST NW STE A
FARGO ND
58102-2955
US

V. Phone/Fax

Practice location:
  • Phone: 701-893-9217
  • Fax: 701-893-9223
Mailing address:
  • Phone: 701-893-9217
  • Fax: 701-893-9223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5390
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: