Healthcare Provider Details

I. General information

NPI: 1942655311
Provider Name (Legal Business Name): RAPHAEL AN HOANG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 05/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12303 JEFFERSON ST NE
BLAINE MN
55434-2000
US

IV. Provider business mailing address

12303 JEFFERSON ST NE
BLAINE MN
55434-2000
US

V. Phone/Fax

Practice location:
  • Phone: 651-800-5678
  • Fax:
Mailing address:
  • Phone: 651-800-5678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number122570
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: