Provider Demographics
NPI:1407995020
Name:THOENNES, MARY JO (RPH)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JO
Last Name:THOENNES
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:JO
Other - Last Name:DYLLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:1516 13TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-8006
Mailing Address - Country:US
Mailing Address - Phone:605-886-6197
Mailing Address - Fax:
Practice Address - Street 1:1516 13TH AVE NE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-8006
Practice Address - Country:US
Practice Address - Phone:605-886-6197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4863183500000X
MN115838183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist