Healthcare Provider Details

I. General information

NPI: 1760697510
Provider Name (Legal Business Name): IDELLA MARIE BRYANT PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 N MAIN STREET
TUBA CITY AZ
86045-0600
US

IV. Provider business mailing address

PO BOX 600
TUBA CITY AZ
86045-0600
US

V. Phone/Fax

Practice location:
  • Phone: 928-283-2754
  • Fax: 928-283-2758
Mailing address:
  • Phone: 928-283-2754
  • Fax: 928-283-2758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14773
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: