Provider Demographics
NPI:1487782850
Name:BACON, CYNTHIA (RPH)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:BACON
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 1:120 S VINE ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIANA
Mailing Address - State:OH
Mailing Address - Zip Code:44408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 S VINE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIANA
Practice Address - State:OH
Practice Address - Zip Code:44408
Practice Address - Country:US
Practice Address - Phone:330-482-3816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-1-22254183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist