Provider Demographics
NPI:1073865929
Name:SMALL, BRANDI SU (PHARMD)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:SU
Last Name:SMALL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:BRANDI
Other - Middle Name:SU
Other - Last Name:MONTOYA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:1080 E OWENS, APT 6
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901
Mailing Address - Country:US
Mailing Address - Phone:435-313-4458
Mailing Address - Fax:
Practice Address - Street 1:2500 E. HUNT DR.
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901
Practice Address - Country:US
Practice Address - Phone:928-537-6937
Practice Address - Fax:509-839-4768
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-02
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV20281183500000X
AZS025568183500000X
WAPH60301358183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist