Healthcare Provider Details

I. General information

NPI: 1689351553
Provider Name (Legal Business Name): RAIEF KILLENY RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2023
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 W OLIVE AVE
MADERA CA
93637-5402
US

IV. Provider business mailing address

812 RIDGEBANK AVE
MADERA CA
93636-8032
US

V. Phone/Fax

Practice location:
  • Phone: 559-674-2182
  • Fax:
Mailing address:
  • Phone: 416-880-6107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number61617
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: