Provider Demographics
NPI:1033525985
Name:PIERSKALLA, GLENN RAPHAEL (RPH)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:RAPHAEL
Last Name:PIERSKALLA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323 HIGHWAY 3 S
Mailing Address - Street 2:TARGET # 1211
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-5172
Mailing Address - Country:US
Mailing Address - Phone:507-403-4014
Mailing Address - Fax:
Practice Address - Street 1:2323 HIGHWAY 3 S
Practice Address - Street 2:TARGET # 1211
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-5172
Practice Address - Country:US
Practice Address - Phone:507-403-4014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-10
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111990183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist