Provider Demographics
NPI:1942655311
Name:HOANG, RAPHAEL AN
Entity Type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:AN
Last Name:HOANG
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 1:12303 JEFFERSON ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-2000
Mailing Address - Country:US
Mailing Address - Phone:651-800-5678
Mailing Address - Fax:
Practice Address - Street 1:12303 JEFFERSON ST NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-2000
Practice Address - Country:US
Practice Address - Phone:651-800-5678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN122570183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist