MEDICARE: RAPHAEL VAYNTRAUB PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	124583	MN

General Provider Information

NPI Number	:	1871128165
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAPHAEL VAYNTRAUB PHARMD

Provider Business Mailing Address
First Line	:	2080 FORD PKWY
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55116-1813
Country	:	US
Telephone Number	:	651-605-3634
Fax Number	:	651-605-3644

Provider Business Practice Location Address
First Line	:	2080 FORD PKWY
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55116-1813
Country	:	US
Telephone Number	:	651-605-3634
Fax Number	:	651-605-3644

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2020
Last Update Date	:	03/06/2020

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