Provider Demographics
NPI:1184149296
Name:RIST, JORDAN (PHARM D)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:RIST
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 PAUL BUNYAN DR NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5603
Mailing Address - Country:US
Mailing Address - Phone:218-751-6380
Mailing Address - Fax:
Practice Address - Street 1:2000 PAUL BUNYAN DR NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5603
Practice Address - Country:US
Practice Address - Phone:218-751-6380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-09
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPHA-PHA-LIC-35850183500000X
MN1239551835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN123955OtherPHARMACIST LICENSE
MTMT35850OtherPHARMACIST LICENSE