MEDICARE: JENNIE DEZIEL

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	114476	MN

General Provider Information

NPI Number	:	1851687271
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIE DEZIEL

Provider Business Mailing Address
First Line	:	1750 ROBERT ST S
Second Line	:	T-2046
City	:	WEST ST PAUL
State	:	MN
Zip	:	55118-3919
Country	:	US
Telephone Number	:	651-455-6626
Fax Number	:	651-455-1903

Provider Business Practice Location Address
First Line	:	1750 ROBERT ST S
Second Line	:	T-2046
City	:	WEST ST PAUL
State	:	MN
Zip	:	55118-3919
Country	:	US
Telephone Number	:	651-455-6626
Fax Number	:	651-455-1903

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

Provider Enumeration Date	:	06/23/2011
Last Update Date	:	06/23/2011

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