Provider Demographics
NPI:1568586949
Name:THEOBALD, JEAN ANN (RPH)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:ANN
Last Name:THEOBALD
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MAPLETON
Mailing Address - State:IA
Mailing Address - Zip Code:51034-1203
Mailing Address - Country:US
Mailing Address - Phone:712-881-1033
Mailing Address - Fax:712-881-1203
Practice Address - Street 1:409 MAIN ST
Practice Address - Street 2:
Practice Address - City:MAPLETON
Practice Address - State:IA
Practice Address - Zip Code:50134-0069
Practice Address - Country:US
Practice Address - Phone:712-881-1033
Practice Address - Fax:712-881-1206
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA17193183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist