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General NPI Number Information
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NPI Number | 1558029181
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Entity Type | Individual
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Provider Name | BRYAN H BRISKE
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Gender | Male
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Dates
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Enumeration Date | 12/01/2021
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Last Update Date | 12/01/2021
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Provider Practice Location Address
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Address Line | 1550 LAKE DR SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49506-2704
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Country | US
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Telephone | 616-235-0747
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Fax |
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Provider Business Mailing Address
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Address Line | 3949 FARR RD
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City | FRUITPORT
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State | MI
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Zip | 49415-9309
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Country | US
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Telephone | 231-578-0658
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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 | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 21251020901
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License Number State | MI
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