=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760162218
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDON DEAN POWELL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2023
-----------------------------------------------------
Last Update Date | 07/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 S VISTA AVE
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83705-2429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-344-2529
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11492 S CAMDEN RD
-----------------------------------------------------
City | DRAPER
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84020-9049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-897-9253
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | P10779
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------