Provider Demographics
NPI:1356890826
Name:IDOURAINE, LYNDA
Entity type:Individual
Prefix:
First Name:LYNDA
Middle Name:
Last Name:IDOURAINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 E 5TH ST APT 240
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-5040
Mailing Address - Country:US
Mailing Address - Phone:520-331-4564
Mailing Address - Fax:
Practice Address - Street 1:500 S 99TH AVE
Practice Address - Street 2:
Practice Address - City:TOLLESON
Practice Address - State:AZ
Practice Address - Zip Code:85353-9700
Practice Address - Country:US
Practice Address - Phone:623-907-4927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS022196183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist