Healthcare Provider Details

I. General information

NPI: 1982961975
Provider Name (Legal Business Name): NICOLE L PUCHALLA PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2012
Last Update Date: 04/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 W MAIN ST
CROSBY MN
56441-1422
US

IV. Provider business mailing address

20 W MAIN ST
CROSBY MN
56441-1422
US

V. Phone/Fax

Practice location:
  • Phone: 218-546-5144
  • Fax: 218-546-7238
Mailing address:
  • Phone: 218-546-5144
  • Fax: 218-546-7238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number120535
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: