Provider Demographics
NPI:1457637423
Name:RAVEN, MARY A (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:RAVEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 BUNKER LAKE BLVD NW
Mailing Address - Street 2:T2025
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-4014
Mailing Address - Country:US
Mailing Address - Phone:763-852-0114
Mailing Address - Fax:763-852-0114
Practice Address - Street 1:2000 BUNKER LAKE BLVD NW
Practice Address - Street 2:T2025
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-4014
Practice Address - Country:US
Practice Address - Phone:763-852-0114
Practice Address - Fax:763-852-0114
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-22
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN120499183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist