Provider Demographics
NPI:1558507558
Name:WACHTL, JASON RYAN (PHARMD, BCACP, CGP)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:RYAN
Last Name:WACHTL
Suffix:
Gender:M
Credentials:PHARMD, BCACP, CGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10501 FLORIDA AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55438-2553
Mailing Address - Country:US
Mailing Address - Phone:952-854-1190
Mailing Address - Fax:952-854-1082
Practice Address - Street 1:10501 FLORIDA AVE S
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55438-2553
Practice Address - Country:US
Practice Address - Phone:952-854-1190
Practice Address - Fax:952-854-1082
Is Sole Proprietor?:No
Enumeration Date:2008-12-21
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN119029183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist