=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629665237
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN DONOVAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2020
-----------------------------------------------------
Last Update Date | 12/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8690 E POINT DOUGLAS RD S
-----------------------------------------------------
City | COTTAGE GROVE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55016-4007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-459-7324
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1369 SCHEFFER AVE
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55116-2245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-330-2942
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835C0205X
-----------------------------------------------------
Taxonomy Name | Critical Care Pharmacist
-----------------------------------------------------
License Number | 124371
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------