Provider Demographics
NPI:1295851228
Name:PEDERSON, JAN E (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:E
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21096 GOLD COAST RD NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-9180
Mailing Address - Country:US
Mailing Address - Phone:218-686-5562
Mailing Address - Fax:218-681-2330
Practice Address - Street 1:215 PENNINGTON AVE
Practice Address - Street 2:PHARMACY
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-2900
Practice Address - Country:US
Practice Address - Phone:218-681-1515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1169881835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN743688200Medicaid