Provider Demographics
NPI:1134428303
Name:HENDERSON, NEALAN RAY (RPH)
Entity type:Individual
Prefix:MR
First Name:NEALAN
Middle Name:RAY
Last Name:HENDERSON
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 1:158 WHISPERING DR
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-9084
Mailing Address - Country:US
Mailing Address - Phone:541-476-6826
Mailing Address - Fax:541-476-6826
Practice Address - Street 1:230 REDWOOD HWY
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5404
Practice Address - Country:US
Practice Address - Phone:541-479-8337
Practice Address - Fax:541-476-1443
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-26
Last Update Date:2011-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6730183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist