Provider Demographics
NPI:1467829283
Name:MINOR, CIARA
Entity Type:Individual
Prefix:
First Name:CIARA
Middle Name:
Last Name:MINOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2630
Mailing Address - Country:US
Mailing Address - Phone:509-760-1322
Mailing Address - Fax:
Practice Address - Street 1:414 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843
Practice Address - Country:US
Practice Address - Phone:208-882-6076
Practice Address - Fax:208-882-6846
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-27
Last Update Date:2018-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60658522183500000X
IDP6700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist