Provider Demographics
NPI:1033489125
Name:HERMAN, BRANT (RPH)
Entity Type:Individual
Prefix:
First Name:BRANT
Middle Name:
Last Name:HERMAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 STEADMAN ST B
Mailing Address - Street 2:
Mailing Address - City:NOME
Mailing Address - State:AK
Mailing Address - Zip Code:99762
Mailing Address - Country:US
Mailing Address - Phone:907-443-3314
Mailing Address - Fax:907-443-2847
Practice Address - Street 1:306 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:NOME
Practice Address - State:AK
Practice Address - Zip Code:99762
Practice Address - Country:US
Practice Address - Phone:907-443-3314
Practice Address - Fax:907-443-2847
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1399183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPH90000Medicaid