Provider Demographics
NPI:1306607957
Name:ADANENE, VINCENT OSAYANMON
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:OSAYANMON
Last Name:ADANENE
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 1:6800 BASS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55428-3935
Mailing Address - Country:US
Mailing Address - Phone:763-533-5804
Mailing Address - Fax:763-537-1841
Practice Address - Street 1:6800 BASS LAKE RD
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55428-3935
Practice Address - Country:US
Practice Address - Phone:763-533-5804
Practice Address - Fax:763-537-1841
Is Sole Proprietor?:No
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN114441183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist