Provider Demographics
NPI:1356659981
Name:CALLAS, RAVEN (PHARMD RPH)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:CALLAS
Suffix:
Gender:F
Credentials:PHARMD RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3112 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-5141
Mailing Address - Country:US
Mailing Address - Phone:307-745-7246
Mailing Address - Fax:
Practice Address - Street 1:3112 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-5141
Practice Address - Country:US
Practice Address - Phone:307-745-7246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3347183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist