Provider Demographics
NPI:1477939593
Name:MAYER, ROBERT ALAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ALAN
Last Name:MAYER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 6TH ST # A
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4653
Mailing Address - Country:US
Mailing Address - Phone:406-396-2361
Mailing Address - Fax:
Practice Address - Street 1:3020 6TH ST # A
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4653
Practice Address - Country:US
Practice Address - Phone:406-396-2361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP7342183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP7342OtherPHARMACIST LICENSE
IDCS39698OtherCONTROLLED SUBSTANCE IDENTIFICATION NUMBER