Provider Demographics
NPI:1720290224
Name:BRUNNER, MICKIE S (PHARMD,, RPH)
Entity Type:Individual
Prefix:
First Name:MICKIE
Middle Name:S
Last Name:BRUNNER
Suffix:
Gender:F
Credentials:PHARMD,, RPH
Other - Prefix:
Other - First Name:MICKIE
Other - Middle Name:S
Other - Last Name:TIMLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:214 W. RAINBOW DR.
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60425
Mailing Address - Country:US
Mailing Address - Phone:708-754-6911
Mailing Address - Fax:
Practice Address - Street 1:ONE INGALLS DR
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426
Practice Address - Country:US
Practice Address - Phone:708-915-4420
Practice Address - Fax:708-915-3108
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist