Healthcare Provider Details

I. General information

NPI: 1982329413
Provider Name (Legal Business Name): RYAN JAMES NULTY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2022
Last Update Date: 10/06/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8170 33RD AVE S
BLOOMINGTON MN
55425-4516
US

IV. Provider business mailing address

2320 TIMBER VIEW DR
HASTINGS MN
55033-8579
US

V. Phone/Fax

Practice location:
  • Phone: 952-883-1000
  • Fax:
Mailing address:
  • Phone: 651-621-4297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number125848
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: