Provider Demographics
NPI:1578772521
Name:THERIAULT, ROBERT HENRY JR (RPH, MBA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:HENRY
Last Name:THERIAULT
Suffix:JR
Gender:M
Credentials:RPH, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 MERIDEN RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766-2401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:243 ELM ST
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:NH
Practice Address - Zip Code:03743-4921
Practice Address - Country:US
Practice Address - Phone:603-542-3423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHR1113183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist