Healthcare Provider Details

I. General information

NPI: 1023359890
Provider Name (Legal Business Name): RENAE CORNELIUS RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2013
Last Update Date: 03/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63802 US HIGHWAY 93 STE B
RONAN MT
59864-3414
US

IV. Provider business mailing address

63802 US HIGHWAY 93 STE B
RONAN MT
59864-3414
US

V. Phone/Fax

Practice location:
  • Phone: 406-676-5600
  • Fax: 406-676-5632
Mailing address:
  • Phone: 406-676-5600
  • Fax: 406-676-5632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number3142
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: