Provider Demographics
NPI:1710377130
Name:GALYEN, RAVEN
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:GALYEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6630 ANCHOR LOOP APT 302
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34212-4432
Mailing Address - Country:US
Mailing Address - Phone:540-848-1425
Mailing Address - Fax:
Practice Address - Street 1:6630 ANCHOR LOOP APT 302
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34212-4432
Practice Address - Country:US
Practice Address - Phone:540-848-1425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-24
Last Update Date:2015-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPSI29793183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPSI29793OtherFLORIDA DEPARTMENT OF HEALTH