MEDICARE: MRS. CASEY ANN THIBODEAU PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	15990-40	WI

General Provider Information

NPI Number	:	1689959710
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CASEY ANN THIBODEAU PHARMD

Provider Business Mailing Address
First Line	:	2301 S ONEIDA ST
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54304-5230
Country	:	US
Telephone Number	:	920-490-0424
Fax Number	:	920-490-0651

Provider Business Practice Location Address
First Line	:	2301 S ONEIDA ST
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54304-5230
Country	:	US
Telephone Number	:	920-490-0424
Fax Number	:	920-490-0651

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2011
Last Update Date	:	10/20/2011

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