Provider Demographics
NPI:1043873995
Name:BRONSELL, JOHN BRONSELL RYAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:JOHN BRONSELL
Middle Name:RYAN
Last Name:BRONSELL
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 1:427 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PLUMMER
Mailing Address - State:ID
Mailing Address - Zip Code:83851-4000
Mailing Address - Country:US
Mailing Address - Phone:208-686-6611
Mailing Address - Fax:
Practice Address - Street 1:427 12TH ST
Practice Address - Street 2:
Practice Address - City:PLUMMER
Practice Address - State:ID
Practice Address - Zip Code:83851-4000
Practice Address - Country:US
Practice Address - Phone:208-686-1931
Practice Address - Fax:208-686-3311
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP74451835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care