Provider Demographics
NPI:1295860260
Name:CHALSTROM, CARL VICTOR (RPH)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:VICTOR
Last Name:CHALSTROM
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 1:1791 HIGHWAY 64 E
Mailing Address - Street 2:
Mailing Address - City:ANAMOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52205-2112
Mailing Address - Country:US
Mailing Address - Phone:319-462-3306
Mailing Address - Fax:319-462-6065
Practice Address - Street 1:1791 HIGHWAY 64 E
Practice Address - Street 2:
Practice Address - City:ANAMOSA
Practice Address - State:IA
Practice Address - Zip Code:52205-2112
Practice Address - Country:US
Practice Address - Phone:319-462-3306
Practice Address - Fax:319-462-6065
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA168971835P2201X
IAC16897183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAC16897OtherSTATE LICENSE NUMBER