Provider Demographics
NPI:1669737839
Name:VERA CHWIALKOWSKI, THERESA (RPH)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:VERA CHWIALKOWSKI
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 1:14175 OLD MARINE TRL N
Mailing Address - Street 2:
Mailing Address - City:MARINE ON SAINT CROIX
Mailing Address - State:MN
Mailing Address - Zip Code:55047-9774
Mailing Address - Country:US
Mailing Address - Phone:651-433-4712
Mailing Address - Fax:651-433-4712
Practice Address - Street 1:1500 CURVE CREST BLVD W
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6040
Practice Address - Country:US
Practice Address - Phone:651-430-4670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115074183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist