Provider Demographics
NPI:1487998936
Name:CARRELL, LOREN RAY (PHARMD)
Entity type:Individual
Prefix:
First Name:LOREN
Middle Name:RAY
Last Name:CARRELL
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 1:526 21ST AVE S
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-8754
Mailing Address - Country:US
Mailing Address - Phone:218-340-4177
Mailing Address - Fax:
Practice Address - Street 1:18601 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:WI
Practice Address - Zip Code:54773-8605
Practice Address - Country:US
Practice Address - Phone:715-538-4361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-23
Last Update Date:2012-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14943183500000X, 1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
No183500000XPharmacy Service ProvidersPharmacist