Provider Demographics
NPI:1053835108
Name:DAHL, BRANDI KAY (PHARMD)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:KAY
Last Name:DAHL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:423-433-6039
Mailing Address - Fax:423-433-6060
Practice Address - Street 1:208 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620
Practice Address - Country:US
Practice Address - Phone:423-989-4050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN43590183500000X
TX60751183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ050636Medicaid