Provider Demographics
NPI:1669829149
Name:HORAN, RAYMOND JR
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:HORAN
Suffix:JR
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 1:1322 SYCAMORE RD
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-2443
Mailing Address - Country:US
Mailing Address - Phone:815-756-1328
Mailing Address - Fax:815-756-5607
Practice Address - Street 1:1322 SYCAMORE RD
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-2443
Practice Address - Country:US
Practice Address - Phone:815-756-1328
Practice Address - Fax:815-756-5607
Is Sole Proprietor?:No
Enumeration Date:2016-05-16
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051033193183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist