Provider Demographics
NPI:1104220854
Name:RAUENHORST, LLOYD
Entity Type:Individual
Prefix:MR
First Name:LLOYD
Middle Name:
Last Name:RAUENHORST
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:PO BOX 575
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:ID
Mailing Address - Zip Code:83850-0575
Mailing Address - Country:US
Mailing Address - Phone:208-682-9122
Mailing Address - Fax:
Practice Address - Street 1:504 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:SMELTERVILLE
Practice Address - State:ID
Practice Address - Zip Code:83868
Practice Address - Country:US
Practice Address - Phone:208-783-2739
Practice Address - Fax:208-783-2825
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5377183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist