Provider Demographics
NPI:1912660291
Name:PAULSON, JAKE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JAKE
Middle Name:
Last Name:PAULSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SOLDIER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:ROSEBUD
Mailing Address - State:SD
Mailing Address - Zip Code:57570-8502
Mailing Address - Country:US
Mailing Address - Phone:651-315-5905
Mailing Address - Fax:
Practice Address - Street 1:400 SOLDIER CREEK DR
Practice Address - Street 2:
Practice Address - City:ROSEBUD
Practice Address - State:SD
Practice Address - Zip Code:57570-8502
Practice Address - Country:US
Practice Address - Phone:605-747-2231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN45404183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist