Provider Demographics
NPI:1265715106
Name:GRODAHL, JILL MARIE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:MARIE
Last Name:GRODAHL
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 1:1999 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-4223
Mailing Address - Country:US
Mailing Address - Phone:515-222-1546
Mailing Address - Fax:515-222-0724
Practice Address - Street 1:1999 GRAND AVE
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-4223
Practice Address - Country:US
Practice Address - Phone:515-222-1546
Practice Address - Fax:515-222-0724
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20466183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist