Healthcare Provider Details

I. General information

NPI: 1316568033
Provider Name (Legal Business Name): BRENT CONRAD BECKNER PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2020
Last Update Date: 05/04/2020
Certification Date: 05/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4077 FIFTH AVE
SAN DIEGO CA
92103-2105
US

IV. Provider business mailing address

10061 RIO SAN DIEGO DR APT 289
SAN DIEGO CA
92108-5679
US

V. Phone/Fax

Practice location:
  • Phone: 907-957-1615
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835C0205X
TaxonomyCritical Care Pharmacist
License Number81567
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: