Healthcare Provider Details

I. General information

NPI: 1982178331
Provider Name (Legal Business Name): BRANDI KAYE LODGE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2019
Last Update Date: 01/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 E GRANT RD
TUCSON AZ
85712-2805
US

IV. Provider business mailing address

1814 N SANTA ROSA AVE
TUCSON AZ
85712-3531
US

V. Phone/Fax

Practice location:
  • Phone: 520-123-4567
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number022701
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: