Provider Demographics
NPI:1295497782
Name:BOURBON, CYNTHIA DENISE (RPH)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:DENISE
Last Name:BOURBON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:DENISE
Other - Last Name:BOURBON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:106 SILVER THREAD LN
Mailing Address - Street 2:
Mailing Address - City:BRANSON WEST
Mailing Address - State:MO
Mailing Address - Zip Code:65737-8990
Mailing Address - Country:US
Mailing Address - Phone:417-272-1112
Mailing Address - Fax:
Practice Address - Street 1:106 SILVER THREAD LN
Practice Address - Street 2:
Practice Address - City:BRANSON WEST
Practice Address - State:MO
Practice Address - Zip Code:65737-8990
Practice Address - Country:US
Practice Address - Phone:417-221-1112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO042757183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist