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General NPI Number Information
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NPI Number | 1518558741
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Entity Type | Individual
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Provider Name | MR. CHARLES MARVIN BRYANT JR.
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Gender | Male
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Dates
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Enumeration Date | 01/30/2021
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Last Update Date | 01/30/2021
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Provider Practice Location Address
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Address Line | 2730 S PRAIRIE AVE
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City | PUEBLO
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State | CO
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Zip | 81005-3167
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Country | US
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Telephone | 719-696-6159
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Fax | 719-696-6170
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Provider Business Mailing Address
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Address Line | 1609 ZUNI RD
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City | PUEBLO
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State | CO
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Zip | 81001-1620
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Country | US
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Telephone | 719-568-5009
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183700000X
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Taxonomy Name | Pharmacy Technician
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License Number | PHATP.0006919
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License Number State | CO
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