Provider Demographics
NPI:1023359890
Name:CORNELIUS, RENAE (RPH)
Entity Type:Individual
Prefix:
First Name:RENAE
Middle Name:
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63802 US HIGHWAY 93 STE B
Mailing Address - Street 2:
Mailing Address - City:RONAN
Mailing Address - State:MT
Mailing Address - Zip Code:59864-3414
Mailing Address - Country:US
Mailing Address - Phone:406-676-5600
Mailing Address - Fax:406-676-5632
Practice Address - Street 1:63802 US HIGHWAY 93 STE B
Practice Address - Street 2:
Practice Address - City:RONAN
Practice Address - State:MT
Practice Address - Zip Code:59864-3414
Practice Address - Country:US
Practice Address - Phone:406-676-5600
Practice Address - Fax:406-676-5632
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3142183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist