Healthcare Provider Details

I. General information

NPI: 1669456109
Provider Name (Legal Business Name): STEPHEN W BRANDT RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 W KETTLEMAN LN S-MART PHARMACY
LODI CA
95240-6050
US

IV. Provider business mailing address

1614 CAMPHOR WAY
LODI CA
95242-4420
US

V. Phone/Fax

Practice location:
  • Phone: 209-339-9805
  • Fax: 209-334-2203
Mailing address:
  • Phone: 209-339-9805
  • Fax: 209-334-2203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number31823
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: