Healthcare Provider Details

I. General information

NPI: 1073199782
Provider Name (Legal Business Name): BREANNA NORTH I PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 03/23/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E CHURCH ST
COLUMBIA AL
36319
US

IV. Provider business mailing address

PO BOX 614
COLUMBIA AL
36319-0614
US

V. Phone/Fax

Practice location:
  • Phone: 334-696-4611
  • Fax:
Mailing address:
  • Phone: 334-696-4611
  • Fax: 334-696-4669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14961
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: