Provider Demographics
NPI:1144597170
Name:FUDER, RYAN B (PHARMD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:B
Last Name:FUDER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2829 ASPEN LAKE DR NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-3100
Mailing Address - Country:US
Mailing Address - Phone:763-792-2985
Mailing Address - Fax:
Practice Address - Street 1:11330 FOUNTAINS DRIVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-1304
Practice Address - Country:US
Practice Address - Phone:763-494-8059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-18
Last Update Date:2022-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1185751835P0018X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist