Provider Demographics
NPI:1437591112
Name:GLOUDEMANS, ALEX
Entity Type:Individual
Prefix:DR
First Name:ALEX
Middle Name:
Last Name:GLOUDEMANS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 S SIDNEY ST
Mailing Address - Street 2:
Mailing Address - City:KIMBERLY
Mailing Address - State:WI
Mailing Address - Zip Code:54136-1960
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3330 E CALUMET ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-4127
Practice Address - Country:US
Practice Address - Phone:920-733-3016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-23
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17089-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist