Provider Demographics
NPI:1962021154
Name:STUKALOVA, SVETLANA
Entity Type:Individual
Prefix:
First Name:SVETLANA
Middle Name:
Last Name:STUKALOVA
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 1:4201 W DIVISION ST STE A124
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-6601
Mailing Address - Country:US
Mailing Address - Phone:320-252-4646
Mailing Address - Fax:
Practice Address - Street 1:4201 W DIVISION ST STE A124
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-6601
Practice Address - Country:US
Practice Address - Phone:320-252-4646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-08
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN123081183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist