Provider Demographics
NPI:1659729234
Name:THUESON, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:THUESON
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 1:1055 S TWIN LAKES AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:ID
Mailing Address - Zip Code:83644-5137
Mailing Address - Country:US
Mailing Address - Phone:208-488-2288
Mailing Address - Fax:
Practice Address - Street 1:65 SE GOODFELLOW ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-3016
Practice Address - Country:US
Practice Address - Phone:541-889-6288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-24
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0015809183500000X
IDP7698183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist