Provider Demographics
NPI:1538586888
Name:ALLISON, THEODORE THEODORE (RPH)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:THEODORE
Last Name:ALLISON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5630 SAINT CROIX TRL
Mailing Address - Street 2:
Mailing Address - City:NORTH BRANCH
Mailing Address - State:MN
Mailing Address - Zip Code:55056-4202
Mailing Address - Country:US
Mailing Address - Phone:651-674-9956
Mailing Address - Fax:651-674-9907
Practice Address - Street 1:5630 SAINT CROIX TRL
Practice Address - Street 2:
Practice Address - City:NORTH BRANCH
Practice Address - State:MN
Practice Address - Zip Code:55056-4202
Practice Address - Country:US
Practice Address - Phone:651-674-9956
Practice Address - Fax:651-674-9907
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111864183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist