Provider Demographics
NPI:1407123565
Name:SMITH, ANGELA M
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 JUERGENS RD SW
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:MN
Mailing Address - Zip Code:55350-2376
Mailing Address - Country:US
Mailing Address - Phone:218-341-6997
Mailing Address - Fax:
Practice Address - Street 1:900 COOPER AVE S
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-6267
Practice Address - Country:US
Practice Address - Phone:320-252-1515
Practice Address - Fax:320-202-1626
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN120692183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist