Provider Demographics
NPI:1114219888
Name:CORNELIUS, CAROL M (PHARMD, RPH)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:M
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 S ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-1238
Mailing Address - Country:US
Mailing Address - Phone:208-947-0967
Mailing Address - Fax:208-947-0967
Practice Address - Street 1:420 S ORCHARD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1238
Practice Address - Country:US
Practice Address - Phone:208-947-0967
Practice Address - Fax:208-947-0967
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6492183500000X
MT5659183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist