Provider Demographics
NPI:1194093955
Name:THIELEN, KATIE JO (PHARMD)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:JO
Last Name:THIELEN
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 1:1008 HIGHWAY 55 E
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-8906
Mailing Address - Country:US
Mailing Address - Phone:763-682-5825
Mailing Address - Fax:
Practice Address - Street 1:1008 HIGHWAY 55 E
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-8906
Practice Address - Country:US
Practice Address - Phone:763-682-5825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118326183500000X
IA20818183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist