Provider Demographics
NPI:1972101152
Name:TIN, TOLY
Entity Type:Individual
Prefix:
First Name:TOLY
Middle Name:
Last Name:TIN
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 1:5619 84 1/2 AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-2171
Mailing Address - Country:US
Mailing Address - Phone:763-607-9461
Mailing Address - Fax:
Practice Address - Street 1:1960 TWIN LAKES PKWY
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-1324
Practice Address - Country:US
Practice Address - Phone:612-788-1478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-11
Last Update Date:2020-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124962183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN124962OtherMN BOARD OF PHARMACY LICENSE