Provider Demographics
NPI:1518628650
Name:SHANKS VAZQUEZ, CARLOS DAMIAN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:DAMIAN
Last Name:SHANKS VAZQUEZ
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 1:655 NICOLLET MALL
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55402-1604
Mailing Address - Country:US
Mailing Address - Phone:612-339-0363
Mailing Address - Fax:
Practice Address - Street 1:655 NICOLLET MALL
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-1604
Practice Address - Country:US
Practice Address - Phone:612-339-0363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN125491183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist