Provider Demographics
NPI:1750534269
Name:BALASCAK, ANGELA (RPH, CGP)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:
Last Name:BALASCAK
Suffix:
Gender:F
Credentials:RPH, CGP
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:THOMSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4663 PINE CONE CIR
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-5401
Mailing Address - Country:US
Mailing Address - Phone:651-260-8461
Mailing Address - Fax:
Practice Address - Street 1:1000 FIANNA WAY
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72919-6987
Practice Address - Country:US
Practice Address - Phone:651-260-8461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118486183500000X
TX43048183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist