Provider Demographics
NPI:1629705280
Name:BOMMERSBACH, MADILYN (PHARMD)
Entity Type:Individual
Prefix:
First Name:MADILYN
Middle Name:
Last Name:BOMMERSBACH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 8TH AVE S UNIT 312
Mailing Address - Street 2:
Mailing Address - City:HOPKINS
Mailing Address - State:MN
Mailing Address - Zip Code:55343-4609
Mailing Address - Country:US
Mailing Address - Phone:701-535-0484
Mailing Address - Fax:
Practice Address - Street 1:3620 TEXAS AVE S
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-4057
Practice Address - Country:US
Practice Address - Phone:952-933-3177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN125700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN125700OtherBOARD OF PHARMACY