Provider Demographics
NPI:1710574504
Name:BRYAN, CONNIE MARIE
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:MARIE
Last Name:BRYAN
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 1:30225 S LYNN MARIE LN
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:OR
Mailing Address - Zip Code:97017-9437
Mailing Address - Country:US
Mailing Address - Phone:503-320-4871
Mailing Address - Fax:
Practice Address - Street 1:16200 SE MILL PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-9868
Practice Address - Country:US
Practice Address - Phone:360-449-6425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0007786183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist