Provider Demographics
NPI:1316277262
Name:TRAYLOR, THOR LIEF (RPH)
Entity type:Individual
Prefix:
First Name:THOR
Middle Name:LIEF
Last Name:TRAYLOR
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 1:2201 S LOOP 256
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801-4701
Mailing Address - Country:US
Mailing Address - Phone:903-723-4705
Mailing Address - Fax:903-723-4703
Practice Address - Street 1:2201 S LOOP 256
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-4701
Practice Address - Country:US
Practice Address - Phone:903-723-4705
Practice Address - Fax:903-723-4703
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-28
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35581183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist