=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508197484
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY L BRENNA PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2010
-----------------------------------------------------
Last Update Date | 01/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6525 UNIVERSITY AVE NE
-----------------------------------------------------
City | FRIDLEY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55432-4331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-586-0730
-----------------------------------------------------
Fax | 763-586-0924
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6525 UNIVERSITY AVE NE
-----------------------------------------------------
City | FRIDLEY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55432-4331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-586-0730
-----------------------------------------------------
Fax | 763-586-0924
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 118473
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 12204
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------