Provider Demographics
NPI:1114256054
Name:SANDIDGE, RAYMOND MARSHALL (RPH)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:MARSHALL
Last Name:SANDIDGE
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 1:1000 W FRANK AVE
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3370
Mailing Address - Country:US
Mailing Address - Phone:936-634-7083
Mailing Address - Fax:
Practice Address - Street 1:1000 W FRANK AVE
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3370
Practice Address - Country:US
Practice Address - Phone:936-634-7083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-23
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29359183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist