Provider Demographics
NPI:1417066184
Name:BRUNER, KELLIE JUNE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:JUNE
Last Name:BRUNER
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 1:539 RESERVATION LINE RD
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:ID
Mailing Address - Zip Code:83522
Mailing Address - Country:US
Mailing Address - Phone:208-962-5542
Mailing Address - Fax:
Practice Address - Street 1:415 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GRANGEVILLE
Practice Address - State:ID
Practice Address - Zip Code:83530
Practice Address - Country:US
Practice Address - Phone:208-983-0725
Practice Address - Fax:208-983-9534
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4886183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist