Provider Demographics
NPI:1184660987
Name:BREIDENBACH, JESSE LEE (PHARM D)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:LEE
Last Name:BREIDENBACH
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 E BROADWAY AVE
Mailing Address - Street 2:HOME INFUSION
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4520
Mailing Address - Country:US
Mailing Address - Phone:701-530-6890
Mailing Address - Fax:701-530-6891
Practice Address - Street 1:900 E BROADWAY AVE
Practice Address - Street 2:HOME INFUSION
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4520
Practice Address - Country:US
Practice Address - Phone:701-530-6890
Practice Address - Fax:701-530-6891
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4784183500000X, 1835N1003X, 1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered183500000XPharmacy Service ProvidersPharmacist
Not Answered1835N1003XPharmacy Service ProvidersPharmacistNutrition Support
Not Answered1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy