MEDICARE: BRIAN ETHAN JAN RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PST.022336	LA
2	183500000X	Pharmacist	66308	TX

General Provider Information

NPI Number	:	1558878827
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN ETHAN JAN RPH

Provider Business Mailing Address
First Line	:	3200 COLONIAL PKWY APT 727
Second Line	:
City	:	BELTON
State	:	TX
Zip	:	76513-5799
Country	:	US
Telephone Number	:	858-837-4620
Fax Number	:

Provider Business Practice Location Address
First Line	:	36065 SANTA FE AVE
Second Line	:
City	:	FORT HOOD
State	:	TX
Zip	:	76544-5060
Country	:	US
Telephone Number	:	254-288-8888
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2018
Last Update Date	:	05/31/2026

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