Provider Demographics
NPI:1871128165
Name:VAYNTRAUB, RAPHAEL (PHARMD)
Entity type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:
Last Name:VAYNTRAUB
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 1:2080 FORD PKWY
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-1813
Mailing Address - Country:US
Mailing Address - Phone:651-605-3634
Mailing Address - Fax:651-605-3644
Practice Address - Street 1:2080 FORD PKWY
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-1813
Practice Address - Country:US
Practice Address - Phone:651-605-3634
Practice Address - Fax:651-605-3644
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124583183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist