Provider Demographics
NPI:1891381281
Name:BARDAL, CAROL JEAN
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:JEAN
Last Name:BARDAL
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 1:10301 HEIDI LN
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-9516
Mailing Address - Country:US
Mailing Address - Phone:952-412-7876
Mailing Address - Fax:
Practice Address - Street 1:7900 MARKET BLVD
Practice Address - Street 2:
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-4565
Practice Address - Country:US
Practice Address - Phone:952-934-2865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-19
Last Update Date:2020-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1112561183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist