Provider Demographics
NPI:1629331913
Name:KOORENNY, BRIAN G
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:G
Last Name:KOORENNY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403
Mailing Address - Country:US
Mailing Address - Phone:509-529-3706
Mailing Address - Fax:509-529-3788
Practice Address - Street 1:400 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-1931
Practice Address - Country:US
Practice Address - Phone:509-758-7475
Practice Address - Fax:509-758-2049
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA11188183500000X
ID4421183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist