Provider Demographics
NPI:1366735870
Name:TAYLOR, CONSTANCE JOYCE (CONNIE TAYLOR)
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:JOYCE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:CONNIE TAYLOR
Other - Prefix:MS
Other - First Name:CONNIE
Other - Middle Name:JOYCE
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:3692 W FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-8020
Mailing Address - Country:US
Mailing Address - Phone:208-765-5323
Mailing Address - Fax:208-772-7176
Practice Address - Street 1:43 W PRAIRIE SHOPPING CTR
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-9854
Practice Address - Country:US
Practice Address - Phone:208-772-5543
Practice Address - Fax:208-772-7176
Is Sole Proprietor?:No
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP3701183500000X
WAPH00009309183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist