Provider Demographics
NPI:1316046543
Name:CONNOLLY, CONNIE JO (RPH)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:JO
Last Name:CONNOLLY
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 1:1620 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:DE WITT
Mailing Address - State:IA
Mailing Address - Zip Code:52742-1087
Mailing Address - Country:US
Mailing Address - Phone:563-659-2106
Mailing Address - Fax:
Practice Address - Street 1:918 W PLATT ST
Practice Address - Street 2:SUITE 2
Practice Address - City:MAQUOKETA
Practice Address - State:IA
Practice Address - Zip Code:52060-2038
Practice Address - Country:US
Practice Address - Phone:563-652-5611
Practice Address - Fax:563-652-6242
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA17824183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist