MEDICARE: JESSE EARL BANDELIN PHARM.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	120021	MN

General Provider Information

NPI Number	:	1538446430
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSE EARL BANDELIN PHARM.D.

Provider Business Mailing Address
First Line	:	18 SE 10TH ST
Second Line	:
City	:	GRAND RAPIDS
State	:	MN
Zip	:	55744-3947
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	18 SE 10TH ST
Second Line	:
City	:	GRAND RAPIDS
State	:	MN
Zip	:	55744-3947
Country	:	US
Telephone Number	:	218-326-0069
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2011
Last Update Date	:	11/07/2011

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