Provider Demographics
NPI:1821383720
Name:WALBY, JENNIE
Entity Type:Individual
Prefix:DR
First Name:JENNIE
Middle Name:
Last Name:WALBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIE
Other - Middle Name:
Other - Last Name:WALBY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8655 E POINT DOUGLAS RD S
Mailing Address - Street 2:T0662
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-4035
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8655 E POINT DOUGLAS RD S
Practice Address - Street 2:T0662
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-4035
Practice Address - Country:US
Practice Address - Phone:651-458-8219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN120001183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist