Provider Demographics
NPI:1891310439
Name:PANCHAL, DOLLY
Entity Type:Individual
Prefix:
First Name:DOLLY
Middle Name:
Last Name:PANCHAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5253 HERITAGE HILLS DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55437-2872
Mailing Address - Country:US
Mailing Address - Phone:612-234-7216
Mailing Address - Fax:
Practice Address - Street 1:14075 HIGHWAY 13 S
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-3100
Practice Address - Country:US
Practice Address - Phone:952-447-1611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN121653183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist