Provider Demographics
NPI:1083375265
Name:RAYMOND, DALTON THOMAS (PHARMACY IMMUNIZER)
Entity Type:Individual
Prefix:
First Name:DALTON
Middle Name:THOMAS
Last Name:RAYMOND
Suffix:
Gender:M
Credentials:PHARMACY IMMUNIZER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5483 DONNA LN
Mailing Address - Street 2:
Mailing Address - City:DRYDEN
Mailing Address - State:MI
Mailing Address - Zip Code:48428-9246
Mailing Address - Country:US
Mailing Address - Phone:810-441-4767
Mailing Address - Fax:
Practice Address - Street 1:3939 S LAPEER RD
Practice Address - Street 2:
Practice Address - City:METAMORA
Practice Address - State:MI
Practice Address - Zip Code:48455-8950
Practice Address - Country:US
Practice Address - Phone:810-678-2331
Practice Address - Fax:810-678-8781
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303040850183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician