=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922124833
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JODY A. DOE RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2007
-----------------------------------------------------
Last Update Date | 12/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 220 4TH AVE SW
-----------------------------------------------------
City | KILLDEER
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58640-8500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-764-5093
-----------------------------------------------------
Fax | 701-764-5094
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 229 TABOR DRIVE PO BOX 238
-----------------------------------------------------
City | KILLDEER
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58640-0238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-764-5623
-----------------------------------------------------
Fax | 701-764-5094
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 4525
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------