Healthcare Provider Details

I. General information

NPI: 1215216841
Provider Name (Legal Business Name): ADAM BRUNELLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2011
Last Update Date: 08/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 E MAIN ST
MESA AZ
85205-7902
US

IV. Provider business mailing address

2093 E MARLENE DR
GILBERT AZ
85296-1523
US

V. Phone/Fax

Practice location:
  • Phone: 480-218-8573
  • Fax:
Mailing address:
  • Phone: 623-210-3378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS018503
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: