Provider Demographics
NPI:1447256722
Name:CARLSON, RYAN LEE
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:LEE
Last Name:CARLSON
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 1:1260 70TH ST SE
Mailing Address - Street 2:
Mailing Address - City:MURDOCK
Mailing Address - State:MN
Mailing Address - Zip Code:56271-7924
Mailing Address - Country:US
Mailing Address - Phone:320-875-2052
Mailing Address - Fax:
Practice Address - Street 1:118 W 5TH ST
Practice Address - Street 2:
Practice Address - City:STARBUCK
Practice Address - State:MN
Practice Address - Zip Code:56381-2426
Practice Address - Country:US
Practice Address - Phone:320-875-2052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN711229-2183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician