Provider Demographics
NPI:1609473933
Name:THIEDE, JOLEEN KAY (RPH)
Entity Type:Individual
Prefix:
First Name:JOLEEN
Middle Name:KAY
Last Name:THIEDE
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 1:18755 70TH WAY N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-3515
Mailing Address - Country:US
Mailing Address - Phone:763-494-5301
Mailing Address - Fax:763-416-4801
Practice Address - Street 1:18755 70TH WAY N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-3515
Practice Address - Country:US
Practice Address - Phone:763-494-5301
Practice Address - Fax:763-416-4801
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-09
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115026183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty