Provider Demographics
NPI:1982961975
Name:PUCHALLA, NICOLE L (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:L
Last Name:PUCHALLA
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 1:20 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:MN
Mailing Address - Zip Code:56441-1422
Mailing Address - Country:US
Mailing Address - Phone:218-546-5144
Mailing Address - Fax:218-546-7238
Practice Address - Street 1:20 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:MN
Practice Address - Zip Code:56441-1422
Practice Address - Country:US
Practice Address - Phone:218-546-5144
Practice Address - Fax:218-546-7238
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN120535183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist