Provider Demographics
NPI:1588804694
Name:THELEN-BACHMEIER, LISA (RPH)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:THELEN-BACHMEIER
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 1:17440 91ST AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-5404
Mailing Address - Country:US
Mailing Address - Phone:763-420-9672
Mailing Address - Fax:763-577-7007
Practice Address - Street 1:2855 CAMPUS DR
Practice Address - Street 2:SUITE 180
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-2649
Practice Address - Country:US
Practice Address - Phone:763-577-7007
Practice Address - Fax:763-577-7196
Is Sole Proprietor?:No
Enumeration Date:2009-03-02
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1141241835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN984660300Medicaid