Provider Demographics
NPI:1356614119
Name:VELLENGA, RAYMOND KEITH (RPH)
Entity type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:KEITH
Last Name:VELLENGA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:MR
Other - First Name:RAY
Other - Middle Name:K
Other - Last Name:VELLENGA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:7617 172ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-8873
Mailing Address - Country:US
Mailing Address - Phone:651-464-5274
Mailing Address - Fax:
Practice Address - Street 1:7617 172ND AVE NE
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-8873
Practice Address - Country:US
Practice Address - Phone:651-464-5274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN110257183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist