Provider Demographics
NPI:1861096042
Name:ESPINOSA, RAYMOND DANIEL (RPH)
Entity type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:DANIEL
Last Name:ESPINOSA
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 1:2935 FIVE FORKS TRICKUM RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-5895
Mailing Address - Country:US
Mailing Address - Phone:770-982-5202
Mailing Address - Fax:678-344-8488
Practice Address - Street 1:2935 FIVE FORKS TRICKUM RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-5895
Practice Address - Country:US
Practice Address - Phone:770-982-5202
Practice Address - Fax:678-344-8488
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-28
Last Update Date:2020-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA013635183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist