Provider Demographics
NPI:1063907178
Name:DAENZER, RAYMOND DOUGLAS (PHARMD)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:DOUGLAS
Last Name:DAENZER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 E VATES ST
Mailing Address - Street 2:
Mailing Address - City:FRANKENMUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48734-1151
Mailing Address - Country:US
Mailing Address - Phone:989-780-2108
Mailing Address - Fax:
Practice Address - Street 1:310 E VATES ST
Practice Address - Street 2:
Practice Address - City:FRANKENMUTH
Practice Address - State:MI
Practice Address - Zip Code:48734-1151
Practice Address - Country:US
Practice Address - Phone:989-780-2108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-30
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302043183183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1154725570Medicaid