Provider Demographics
NPI:1104315225
Name:SCHENK, GRAYSON NORMAN
Entity type:Individual
Prefix:
First Name:GRAYSON
Middle Name:NORMAN
Last Name:SCHENK
Suffix:
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 1:2832 W TENUTA ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-3230
Mailing Address - Country:US
Mailing Address - Phone:208-201-1404
Mailing Address - Fax:
Practice Address - Street 1:2100 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6441
Practice Address - Country:US
Practice Address - Phone:208-467-5159
Practice Address - Fax:208-467-5447
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6641183500000X
NV18143183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist