Provider Demographics
NPI:1780431494
Name:RENOUF, RAYMOND HENRY III
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:HENRY
Last Name:RENOUF
Suffix:III
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 1:1599 GRANDVIEW LN
Mailing Address - Street 2:
Mailing Address - City:ASHTON
Mailing Address - State:ID
Mailing Address - Zip Code:83420-5113
Mailing Address - Country:US
Mailing Address - Phone:208-840-0548
Mailing Address - Fax:
Practice Address - Street 1:23 S 8TH ST STE 2
Practice Address - Street 2:
Practice Address - City:ASHTON
Practice Address - State:ID
Practice Address - Zip Code:83420-5211
Practice Address - Country:US
Practice Address - Phone:208-652-3932
Practice Address - Fax:208-652-3470
Is Sole Proprietor?:No
Enumeration Date:2024-05-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP7296183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist