Provider Demographics
NPI:1689959710
Name:THIBODEAU, CASEY ANN (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:CASEY
Middle Name:ANN
Last Name:THIBODEAU
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 1:2301 S ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5230
Mailing Address - Country:US
Mailing Address - Phone:920-490-0424
Mailing Address - Fax:920-490-0651
Practice Address - Street 1:2301 S ONEIDA ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5230
Practice Address - Country:US
Practice Address - Phone:920-490-0424
Practice Address - Fax:920-490-0651
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15990-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist