Provider Demographics
NPI:1326110602
Name:TETRICK, JILL ANN (RPH)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:ANN
Last Name:TETRICK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8345 FAIRCHILD AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNDS VIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55112-6122
Mailing Address - Country:US
Mailing Address - Phone:763-785-0574
Mailing Address - Fax:
Practice Address - Street 1:1580 BEAM AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1127
Practice Address - Country:US
Practice Address - Phone:651-255-8480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11450321835X0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835X0200XPharmacy Service ProvidersPharmacistOncology