Provider Demographics
NPI:1609151679
Name:BODICHARLA, JENNIFER A (PHARMD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:BODICHARLA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:A
Other - Last Name:KOPPA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:611 ST JOSEPH AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-1832
Mailing Address - Country:US
Mailing Address - Phone:715-355-9640
Mailing Address - Fax:715-355-9675
Practice Address - Street 1:611 ST JOSEPH AVE
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-1832
Practice Address - Country:US
Practice Address - Phone:715-221-8959
Practice Address - Fax:715-355-9675
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15440-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist