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NPI Code Detail

MEDICARE: DR. JASON RYAN WACHTL PHARM.D., BCACP, CGP

MEDICARE: DR. JASON RYAN WACHTL PHARM.D., BCACP, CGP
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
1183500000XPharmacist119029MN

General Provider Information

NPI Number : 1558507558
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JASON RYAN WACHTL PHARM.D., BCACP, CGP
Provider Business Mailing Address
First Line : 10501 FLORIDA AVE S
Second Line :
City : BLOOMINGTON
State : MN
Zip : 55438-2553
Country : US
Telephone Number : 952-854-1190
Fax Number : 952-854-1082
Provider Business Practice Location Address
First Line : 10501 FLORIDA AVE S
Second Line :
City : BLOOMINGTON
State : MN
Zip : 55438-2553
Country : US
Telephone Number : 952-854-1190
Fax Number : 952-854-1082
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/21/2008
Last Update Date : 06/17/2014

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