Provider Demographics
NPI:1487013819
Name:PODEVELS, ANGELA
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:PODEVELS
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 1:2415 STATE RD
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-6137
Mailing Address - Country:US
Mailing Address - Phone:608-788-0803
Mailing Address - Fax:608-788-5084
Practice Address - Street 1:2415 STATE RD
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-6137
Practice Address - Country:US
Practice Address - Phone:608-788-0803
Practice Address - Fax:608-788-5084
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-12
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17157-40183500000X
MN122053183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist