Provider Demographics
NPI:1669507299
Name:TSHANE, PHEMELO B (PHARMD)
Entity type:Individual
Prefix:DR
First Name:PHEMELO
Middle Name:B
Last Name:TSHANE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1294 FIFIELD PL
Mailing Address - Street 2:
Mailing Address - City:FALCON HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55108-1103
Mailing Address - Country:US
Mailing Address - Phone:651-646-8042
Mailing Address - Fax:
Practice Address - Street 1:701 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411-2611
Practice Address - Country:US
Practice Address - Phone:612-302-8740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN119580183500000X
MD16433183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN119580OtherREGISTERED PHARMACIST LICENSE
MD16433OtherREGISTERED PHARMACIST LICENSE