Provider Demographics
NPI:1457765398
Name:JORSTAD, CAMALA (RPH)
Entity type:Individual
Prefix:
First Name:CAMALA
Middle Name:
Last Name:JORSTAD
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W4855 HICKORY HILLS RD
Mailing Address - Street 2:
Mailing Address - City:CHILTON
Mailing Address - State:WI
Mailing Address - Zip Code:53014-9724
Mailing Address - Country:US
Mailing Address - Phone:920-254-7270
Mailing Address - Fax:
Practice Address - Street 1:577 S TAYLOR DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-4234
Practice Address - Country:US
Practice Address - Phone:920-459-7467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15393-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist