Provider Demographics
NPI:1740309236
Name:BRUNNER, MOLLY ANN (RPH)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:ANN
Last Name:BRUNNER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3770 BIRDIE CT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80922-3063
Mailing Address - Country:US
Mailing Address - Phone:719-591-7336
Mailing Address - Fax:
Practice Address - Street 1:25 N SPRUCE ST
Practice Address - Street 2:PHARMACY (119)
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-1436
Practice Address - Country:US
Practice Address - Phone:719-327-5660
Practice Address - Fax:719-633-5737
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19331183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist