Provider Demographics
NPI:1629341953
Name:HINO-BOURASSA, CAROLYN E
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:E
Last Name:HINO-BOURASSA
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:PO BOX 246
Mailing Address - Street 2:
Mailing Address - City:GARBERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95542-0246
Mailing Address - Country:US
Mailing Address - Phone:707-923-3399
Mailing Address - Fax:707-923-3539
Practice Address - Street 1:1006 W WABASH AVE
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-2121
Practice Address - Country:US
Practice Address - Phone:707-441-0920
Practice Address - Fax:707-441-0923
Is Sole Proprietor?:No
Enumeration Date:2012-02-16
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37122183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist