Provider Demographics
NPI:1942781141
Name:BARNUM, CONNIE SUE
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:SUE
Last Name:BARNUM
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 1:265 S EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5907
Mailing Address - Country:US
Mailing Address - Phone:208-319-0543
Mailing Address - Fax:208-319-0549
Practice Address - Street 1:265 S EAGLE RD
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-5907
Practice Address - Country:US
Practice Address - Phone:208-319-0543
Practice Address - Fax:208-319-0549
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCT19000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist