Provider Demographics
NPI:1215204094
Name:RANHEIM, THEODORE GLEN (RPH)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:GLEN
Last Name:RANHEIM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:MR
Other - First Name:THEODORE
Other - Middle Name:GLEN
Other - Last Name:RANHEIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:7131 OAK POINTE CURV
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55438-3403
Mailing Address - Country:US
Mailing Address - Phone:952-941-3568
Mailing Address - Fax:
Practice Address - Street 1:7131 OAK POINTE CURV
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55438-3403
Practice Address - Country:US
Practice Address - Phone:952-941-3568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN110203183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist