Provider Demographics
NPI:1790032431
Name:WARREN, WYNNONA SARAH (PHARMD)
Entity type:Individual
Prefix:DR
First Name:WYNNONA
Middle Name:SARAH
Last Name:WARREN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204
Mailing Address - Country:US
Mailing Address - Phone:208-478-8510
Mailing Address - Fax:208-235-1328
Practice Address - Street 1:911 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204
Practice Address - Country:US
Practice Address - Phone:208-478-8510
Practice Address - Fax:208-235-1328
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6627183500000X
UT8069703-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist