Provider Demographics
NPI:1710267273
Name:OSTERBERG, JAN
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:OSTERBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4850 N LINDER RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6159
Mailing Address - Country:US
Mailing Address - Phone:208-319-0047
Mailing Address - Fax:208-319-0053
Practice Address - Street 1:4850 N LINDER RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-6159
Practice Address - Country:US
Practice Address - Phone:208-319-0047
Practice Address - Fax:208-319-0053
Is Sole Proprietor?:No
Enumeration Date:2011-08-27
Last Update Date:2011-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5533183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist