Provider Demographics
NPI:1437817475
Name:THEOBALD, MICHAEL TIMOTHY (RPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TIMOTHY
Last Name:THEOBALD
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 1:2425 MUSCATINE AVE
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240-6647
Mailing Address - Country:US
Mailing Address - Phone:319-358-1358
Mailing Address - Fax:
Practice Address - Street 1:2425 MUSCATINE AVE
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240-6647
Practice Address - Country:US
Practice Address - Phone:319-358-1358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA15770183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist