Provider Demographics
NPI:1710409792
Name:REAL, ALYSSA LOUISE (PHARMD)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:LOUISE
Last Name:REAL
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 1:850 SARAZIN ST
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-4335
Mailing Address - Country:US
Mailing Address - Phone:715-529-0052
Mailing Address - Fax:
Practice Address - Street 1:1881 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6200
Practice Address - Country:US
Practice Address - Phone:507-625-1660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN123403183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist