Provider Demographics
NPI:1245836261
Name:SLETTEN, GARY (RPH)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:SLETTEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1623 WINDIGO LN
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-3550
Mailing Address - Country:US
Mailing Address - Phone:952-303-9345
Mailing Address - Fax:
Practice Address - Street 1:1623 WINDIGO LN
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-3550
Practice Address - Country:US
Practice Address - Phone:952-303-9345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-06
Last Update Date:2020-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN114880183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist