Provider Demographics
NPI:1407475239
Name:VANG, MALINI
Entity Type:Individual
Prefix:
First Name:MALINI
Middle Name:
Last Name:VANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7178 JOLIET AVE S
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-3624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:915 WILDWOOD RD
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55115-1847
Practice Address - Country:US
Practice Address - Phone:651-426-7333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-12
Last Update Date:2020-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124581183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist