Provider Demographics
NPI:1053655852
Name:MCCONNELL, NATHAN BROCK
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:BROCK
Last Name:MCCONNELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:JULESBURG
Mailing Address - State:CO
Mailing Address - Zip Code:80737-1519
Mailing Address - Country:US
Mailing Address - Phone:618-499-2551
Mailing Address - Fax:
Practice Address - Street 1:121 CEDAR ST
Practice Address - Street 2:
Practice Address - City:JULESBURG
Practice Address - State:CO
Practice Address - Zip Code:80737-1519
Practice Address - Country:US
Practice Address - Phone:618-499-2551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-16
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO19402183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist