Provider Demographics
NPI:1285269514
Name:ELDHEBY, VIVIAN LEWIS (PHARMACIST)
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:LEWIS
Last Name:ELDHEBY
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 MARYLAND AVE E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-2511
Mailing Address - Country:US
Mailing Address - Phone:651-774-1005
Mailing Address - Fax:
Practice Address - Street 1:810 MARYLAND AVE E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-2511
Practice Address - Country:US
Practice Address - Phone:651-774-1005
Practice Address - Fax:
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
MN124165183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist