Provider Demographics
NPI:1689351553
Name:KILLENY, RAIEF (RPH)
Entity Type:Individual
Prefix:
First Name:RAIEF
Middle Name:
Last Name:KILLENY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 RIDGEBANK AVE
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93636-8032
Mailing Address - Country:US
Mailing Address - Phone:416-880-6107
Mailing Address - Fax:
Practice Address - Street 1:335 W OLIVE AVE
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93637-5402
Practice Address - Country:US
Practice Address - Phone:559-674-2182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61617183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist