Provider Demographics
NPI:1235392721
Name:EICKSTAEDT, JENNIFER ELLEN (PHARMD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELLEN
Last Name:EICKSTAEDT
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ELLEN
Other - Last Name:OESTREICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:507-284-2021
Mailing Address - Fax:
Practice Address - Street 1:200 1ST ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55905-0001
Practice Address - Country:US
Practice Address - Phone:507-284-2021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-06
Last Update Date:2008-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN119323183500000X
WI14913-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1609970664Medicaid