=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912599895
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDON GLENN MICHAEL PHARM.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2021
-----------------------------------------------------
Last Update Date | 02/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 134 BEVILL AVENUE
-----------------------------------------------------
City | GOSNELL
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-751-9242
-----------------------------------------------------
Fax | 870-751-9291
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 245 GREENE 687 RD
-----------------------------------------------------
City | PARAGOULD
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72450-5174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-476-0006
-----------------------------------------------------
Fax | 870-751-9291
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PD10791
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------