Provider Demographics
NPI:1942351093
Name:PORTER, ALLEN WAYNE
Entity Type:Individual
Prefix:MR
First Name:ALLEN
Middle Name:WAYNE
Last Name:PORTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 ROBERT ST S
Mailing Address - Street 2:C/O CUB PHARMACY
Mailing Address - City:W ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118-3924
Mailing Address - Country:US
Mailing Address - Phone:651-451-1113
Mailing Address - Fax:651-451-9109
Practice Address - Street 1:2001 ROBERT ST S
Practice Address - Street 2:C/O CUB PHARMACY
Practice Address - City:W ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-3924
Practice Address - Country:US
Practice Address - Phone:651-451-1113
Practice Address - Fax:651-451-9109
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1128561835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy