Healthcare Provider Details

I. General information

NPI: 1922124833
Provider Name (Legal Business Name): JODY A. DOE RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 4TH AVE SW
KILLDEER ND
58640-8500
US

IV. Provider business mailing address

229 TABOR DRIVE PO BOX 238
KILLDEER ND
58640-0238
US

V. Phone/Fax

Practice location:
  • Phone: 701-764-5093
  • Fax: 701-764-5094
Mailing address:
  • Phone: 701-764-5623
  • Fax: 701-764-5094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number4525
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: