Healthcare Provider Details

I. General information

NPI: 1609178458
Provider Name (Legal Business Name): MARK BRENNAN R.PH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2010
Last Update Date: 11/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 ELKS POINT RD
ZEPHYR COVE NV
89448-9800
US

IV. Provider business mailing address

PO BOX 11265
ZEPHYR COVE NV
89448-3265
US

V. Phone/Fax

Practice location:
  • Phone: 775-338-4145
  • Fax: 775-586-9019
Mailing address:
  • Phone: 775-338-4145
  • Fax: 775-586-9019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number017631
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0011837
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number64139
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: