Healthcare Provider Details

I. General information

NPI: 1992465306
Provider Name (Legal Business Name): JATTICORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2021
Last Update Date: 12/27/2021
Certification Date: 12/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 42ND ST S
FARGO ND
58103-2119
US

IV. Provider business mailing address

900 42ND ST S
FARGO ND
58103-2119
US

V. Phone/Fax

Practice location:
  • Phone: 800-633-4227
  • Fax:
Mailing address:
  • Phone: 800-633-4227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JIMMY THOMAS
Title or Position: CEO
Credential:
Phone: 701-492-0555