Provider Demographics
NPI:1205041258
Name:LICOR, RAYNOLD JOSE (RPH,CCP)
Entity Type:Individual
Prefix:MR
First Name:RAYNOLD
Middle Name:JOSE
Last Name:LICOR
Suffix:
Gender:M
Credentials:RPH,CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 ELRAY RD
Mailing Address - Street 2:
Mailing Address - City:MORRIS PLAINS
Mailing Address - State:NJ
Mailing Address - Zip Code:07950-3115
Mailing Address - Country:US
Mailing Address - Phone:973-401-9898
Mailing Address - Fax:
Practice Address - Street 1:20 ELRAY RD
Practice Address - Street 2:
Practice Address - City:MORRIS PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07950-3115
Practice Address - Country:US
Practice Address - Phone:973-401-9898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRI20620183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist